Ohio Supreme Court rejects massive opioid verdict

The Ohio Supreme Court recently that the state's product liability law prohibits counties from bringing public nuisance claims against national pharmaceutical chains as they did as part of national opioid litigation, a decision that could overturn a $650 million judgment against the pharmacies,  reported The Associated Press and WOSU in Columbus.

An attorney for the counties called the decision “devastating.”

Justices were largely unanimous in their interpretation of an arcane disagreement over the state law, which had emerged in a lawsuit brought by Lake and Trumbull counties outside Cleveland against CVS, Walgreens and Walmart.

The counties won their initial lawsuit — and were awarded $650 million in damages by a federal judge in 2022 — but the pharmacies had disputed the court's reading of the Ohio Product Liability Act, which they said protected them from such sanctions.

In an opinion written by Justice Joseph Deters, the court found that Ohio state lawmakers intended the law to prevent “all common law product liability causes of action" — even if they don't seek compensatory damages but merely “equitable relief” for the communities.

“The plain language of the OPLA abrogates product-liability claims, including product-related public-nuisance claims seeking equitable relief,” he wrote. “We are constrained to interpret the statute as written, not according to our own personal policy preferences.”

Two of the Republican-dominated court's Democratic justices disagreed on that one point, while concurring on the rest of the judgment.

“Any award to abate a public nuisance like the opioid epidemic would certainly be substantial in size and scope, given that the claimed nuisance is both long-lasting and widespread,” Justice Melody Stewart wrote in an opinion joined by Justice Michael Donnelly. “But just because an abatement award is of substantial size and scope does not mean it transforms it into a compensatory-damages award.”

In a statement, the plaintiffs' co-liaison counsel in the national opioid litigation, Peter Weinberger, of the Cleveland-based law firm Spangenberg Shibley & Liber, lamented the decision.

“This ruling will have a devastating impact on communities and their ability to police corporate misconduct," he said. “We have used public nuisance claims across the country to obtain nearly $60 billion in opioid settlements, including nearly $1 billion in Ohio alone, and the Ohio Supreme Court’s ruling undermines the very legal basis that drove this result.”

But Weinberger said Tuesday's ruling would not be the end, and that communities would continue to fight “through other legal avenues.”

"We remain steadfast in our commitment to holding all responsible parties to account as this litigation continues nationwide,” he said.

In his 2022 ruling, U.S. District Judge Dan Polster said that the money awarded to Lake and Trump counties would be used to the fight the opioid crisis. Attorneys at the time put the total price tag at $3.3 billion for the damage done.

Lake County was to receive $306 million over 15 years. Trumbull County was to receive $344 million over the same period. Nearly $87 million was to be paid immediately to cover the first two years of payments.

A jury returned a verdict in favor of the counties in November 2021, after a six-week trial. It was then left to the judge to decide how much the counties should receive. He heard testimony the next May to determine damages.

The counties convinced the jury that the pharmacies played an outsized role in creating a public nuisance in the way they dispensed pain medication. It was the first time pharmacy companies completed a trial to defend themselves in a drug crisis that has killed a half-million Americans since 1999.

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Purdue Pharma's Sackler family reaches another deal with states

Members of the billionaire Sackler family and their company, Purdue Pharma, have reached a deal with a group of states that had long resisted the company’s bankruptcy plan — a crucial step toward funneling billions of dollars from the family’s fortune to addiction treatment programs nationwide, according to a court filing, reported by The New York Times.

If Judge Robert Drain, who has presided over Purdue’s bankruptcy proceedings in White Plains, N.Y., approves the agreement, the Sacklers would pay as much as $6 billion to help communities address the damage from the opioid crisis. In return, Sackler family members would get the prize they insisted upon for nearly three years: an end to all current and future civil claims against them over the company’s prescription opioid business.

The Sacklers’ liability protection would not extend to criminal prosecutions.

The deal still faces potential hurdles in the courts, but it is the first time in three years of negotiations that all states have accepted a settlement agreement with Purdue Pharma and the Sacklers. The new agreement includes an increase of at least $1 billion in the amount the Sacklers would pay. In addition to the family’s money, Purdue itself is contributing, through cash and revenue from future sales, payments expected to amount to $1.5 billion by 2024, with far more to come.

The agreement marks a significant moment in the national opioid litigation, an effort by state, local and tribal governments to hold companies across the vast pharmaceutical industry accountable for the crisis of opioid addiction that led to at least 500,000 deaths since 1999.

Though cases have been filed against dozens of companies, Purdue became the target of the earliest and greatest number of lawsuits, because its signature opioid painkiller, OxyContin, initially dominated the market.

“We’re pleased with the settlement achieved in mediation, under which all of the additional settlement funds will be used for opioid abatement programs, overdose rescue medicines and victims,” Purdue said in a written statement. “With this mediation result, we continue on track to proceed through the appeals process on an expedited schedule, and we hope to swiftly deliver these resources.”

While the deal is a breakthrough, it is likely to leave many people disappointed that members of the Sackler family did not acknowledge wrongdoing or any personal responsibility for the public health .

In a statement attached to the court filing, the Sacklers said: “While the families have acted lawfully in all respects, they sincerely regret that OxyContin, a prescription medicine that continues to help people suffering from chronic pain, unexpectedly became part of an opioid crisis that has brought grief and loss to far too many families and communities.”

Other manufacturers, distributors and big retailers such as C.V.S., Walgreens and Walmart, are still defendants in opioid cases. A few have resulted in verdicts, with mixed outcomes for plaintiffs and the company defendants. Some significant settlements have already been reached, notably a $26 billion agreement last month by three major distributors — AmerisourceBergen, Cardinal Health and McKesson — along with Johnson & Johnson and states and localities, and a separate one with tribes. But seasoned lawyers involved in the cases said it will take years to resolve them all.

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Pharmacies take a hit with Ohio opioid verdict

CVS, Walgreens and Walmart pharmacies recklessly distributed massive amounts of pain pills in two Ohio counties, a federal jury said in a verdict that could set the tone for U.S. city and county governments that want to hold pharmacies accountable for their roles in the opioid crisis, reported The Associated Press.

Lake and Trumbull counties blamed the three chain pharmacies for not stopping the flood of pills that caused hundreds of overdose deaths and cost each of the two counties about $1 billion, said their attorney, who in court compared the pharmacies’ dispensing to a gumball machine.

How much the pharmacies must pay in damages will be decided in the spring by a federal judge.

It’s the first time pharmacy companies completed a trial to defend themselves in a drug crisis that killed a half-million Americans over the past two decades.

The counties convinced the jury that the pharmacies played an outsized role in creating a public nuisance in the way they dispensed pain medication into their communities.

“The law requires pharmacies to be diligent in dealing drugs. This case should be a wake-up call that failure will not be accepted,” said Mark Lanier, an attorney for the counties.

“The jury sounded a bell that should be heard through all pharmacies in America,” Lanier said.

Attorneys for the pharmacy chains maintained they had policies to stem the flow of pills when their pharmacists had concerns and would notify authorities about suspicious orders from doctors. They also said it was doctors who controlled how many pills were prescribed for legitimate medical needs.

CVSHealth, Walgreen Co. and Walmart Inc. said they will appeal.

Walmart said in a statement that the counties’ attorneys sued “in search of deep pockets while ignoring the real causes of the opioid crisis — such as pill mill doctors, illegal drugs, and regulators asleep at the switch — and they wrongly claimed pharmacists must second-guess doctors in a way the law never intended and many federal and state health regulators say interferes with the doctor-patient relationship.”

Walgreen spokesperson Fraser Engerman characterized the case as an unsustainable effort “to resolve the opioid crisis with an unprecedented expansion of public nuisance law.”

The company “never manufactured or marketed opioids nor did we distribute them to the ‘pill mills’ and internet pharmacies that fueled this crisis,” Engerman said in a statement.

A statement from CVS spokesperson Mike DeAngelis noted: “As plaintiffs’ own experts testified, many factors have contributed to the opioid abuse issue, and solving this problem will require involvement from all stakeholders in our health care system and all members of our community.”

Two chains — Rite Aid and Giant Eagle — already had settled lawsuits with the two Ohio counties.

Lanier said during trial that the pharmacies were attempting to blame everyone but themselves.

The opioid crisis has overwhelmed courts, social services agencies and law enforcement in Ohio’s blue-collar corner east of Cleveland, leaving behind heartbroken families and babies born to addicted mothers, Lanier told jurors.

Roughly 80 million prescription painkillers were dispensed in Trumbull County alone between 2012 and 2016 — equivalent to 400 for every resident. In Lake County, some 61 million pills were distributed during that period.

The rise in physicians prescribing pain medications such as oxycodone and hydrocodone came as medical groups began recognizing that patients have the right to be treated for pain, Kaspar Stoffelmayr, an attorney for Walgreens, said at the opening of the trial.

The problem, he said, was “pharmaceutical manufacturers tricked doctors into writing way too many pills.”

The counties said pharmacies should be the last line of defense to prevent the pills from getting into the wrong hands.

They didn’t hire enough pharmacists and technicians or train them to stop that from happening and failed to implement systems that could flag suspicious orders, Lanier said.

The committee of lawyers for the local governments suing the drug industry in federal courts called Tuesday’s verdict “a milestone victory” and “overdue reckoning.”

“For decades, pharmacy chains have watched as the pills flowing out of their doors cause harm and failed to take action as required by law,” the committee said in a statement. “Instead, these companies responded by opening up more locations, flooding communities with pills, and facilitating the flow of opioids into an illegal, secondary market.”

The trial before U.S. District Judge Dan Polster in Cleveland was part of a broader constellation of about 3,000 federal opioid lawsuits consolidated under the judge’s supervision. Other cases are moving ahead in state courts.

Kevin Roy, chief public policy officer at Shatterproof, an organization that advocates for solutions to addiction, said the verdict could lead pharmacies to follow the path of major distribution companies and some drugmakers that have reached nationwide settlements of opioid cases worth billions. So far, no pharmacy has reached a nationwide settlement.

“It’s a signal that the public, at least in select places, feels that there’s been exposure and needs to be remedied,” Roy said.

The government claims against drugmakers, distributors and pharmacies hinge on state and local public nuisance laws.

Roy noted that courts haven’t been consistent on whether those laws apply to such cases. “There’s been a variety of different decisions lately that should give us reason to be cautious about what this really means in the grand scheme,” he said.

Two recent rulings went against the theory. More cases are heading toward rulings.

Trials against drugmakers in New York and distribution companies in Washington state are underway. A trial of claims against distribution companies in West Virginia wrapped up, but the judge hasn’t given a verdict.

Earlier in November, a California judge ruled in favor of top drug manufacturers in a lawsuit with three counties and the city of Oakland. The judge said the governments hadn’t proven that the pharmaceutical companies used deceptive marketing to increase unnecessary opioid prescriptions and create a public nuisance.

Also this month, Oklahoma’s supreme court overturned a 2019 judgment for $465 million in a suit brought by the state against drugmaker Johnson & Johnson.

Other lawsuits have resulted in big settlements or proposed settlements before trials were completed.

The jury’s decision in Cleveland had little effect on the stock of CVS, Walgreens and Walmart, which all closed higher Tuesday on Wall Street.

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Drug overdoses continue to rise nationwide

 Even as the state races to vaccinate thousands of Pennsylvanians against COVID-19, public health officials are still waging an ongoing fight against substance abuse, reported the Pennsylvania Capital-Star.

Preliminary data compiled by the federal Centers for Disease Control and Prevention shows that 88,295 people nationwide died from a drug overdose between August 2019 and August 2020, a 27 percent increase from the previous year, NBC News-Montana reported. Opioids and synthetic opioids, such as fentanyl, were responsible for most of the fatalities, according to NBC News.

In Pennsylvania, the number of reported deaths increased by 17.1 percent during that August to August timeframe, from 4,277 in 2019 to 5,008 in 2020, the CDC data showed.

To help combat that wave of abuse, the state Department of Drug and Alcohol Services has announced that it will award $2.7 million in grants to what are known as "recover community groups" that help people who are in recovery from substance use disorder.

Such groups are "non-profit organizations led and governed by representatives of local communities of recovery. These organizations are comprised of staff and volunteers from the recovery community," DDAP spokesperson Alison Gantz told the Capital-Star in an email. The RASE Project in Harrisburg is an example of such a group. 

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GateHouse: This country’s other growing and deadly epidemic

Matthew T. Mangino

GateHouse Media

May 8, 2020

The Centers for Disease Control and Prevention (CDC) have been engrossed in a battle to control an epidemic in this country that in 2018 alone took 67,367 lives. The epidemic is not a new strain of influenza, Ebola or some other deadly infectious disease. The epidemic is drug abuse resulting in overdose deaths.

According to the CDC, drug overdoses are the leading cause of accidental death in the United States. Nearly 70% of the 67,367 deaths in 2018 involved an opioid. Opioid addiction is the driving force behind the epidemic.

Ironically, the birth of the opioid epidemic can be traced to an effort to help people fight chronic pain. OxyContin, a time-release pain reliever, was approved by the government in 1995 and launched for use in the U.S. in 1996. FDA approval was granted to Purdue Pharma, a family-owned business, because of the drug’s 12-hour time-release component. At the time those suffering from chronic pain only had temporary relief every four hours. Within a couple of years, OxyContin exploded onto the illicit drug scene. The time-release aspect of OxyContin was easily defeated by chewing or crushing the tablet - causing a powerful high. Purdue had the opportunity to stop the supply of OxyContin to offices and clinics across the country that were serving as nothing more than pill mills generating enormous profit and providing very little medical care.

Purdue Pharma is a privately held company owned by the Sackler family. Late last year, the family agreed to pay $3 billion over the next seven years to victims’ families, reported the New York Times.

Some of the states with the highest rates of death due to drug overdose are West Virginia (51.5 per 100,000), Pennsylvania (36.1 per 100,000) and Ohio (35.9 per 100,000). The magnitude of the opioid epidemic comes into focus when one compares the overdose deaths with the current COVID-19 death rate in those states, West Virginia (2.7 per 100,000), Pennsylvania (22.6 per 100,000) and Ohio (8.9 per 100,000).

The CDC acknowledges that a pandemic in the midst of an epidemic can be catastrophic. Opioid-related deaths are on the rise during the COVID-19 pandemic.

Brittany Shultz, a substance abuse specialist with the York County Opioid Collaborative in central Pennsylvania explained to WHP-TV in Harrisburg how “a combination of fears and increased isolation during the COVID-19 pandemic has contributed to the rise in overdose deaths.”

Restrictions on movement may lead those with a substance abuse disorder to opt to purchase drugs from less trusted sources, raising the risk of overdosing on drugs that may be stronger than anticipated or tainted.

Narcan, an opioid overdose antidote, has been hailed as a miracle drug. The drug administered by medical staff, police officers and even fellow drug users have pulled people out of a deadly overdose by administering an easy-to-use antidote.

Even in spite of readily available Narcan, overdoses continue to rise. Some suggest that drug users locked down in their homes during the pandemic don’t have friends to call for help or to administer an antidote.

The COVID-19 pandemic has complicated the lives of those in recovery. The loss of employment and social relationships has caused considerable mental health hardship to those already vulnerable to risky behavior.

While this country wages war and dedicates enormous attention and resources to this mysterious and deadly virus, and rightfully so, this country cannot afford to ignore a killer that has been with us for years and will continue to plague America for years to come.
Matthew T. Mangino is of counsel with Luxenberg, Garbett, Kelly & George P.C. His book “The Executioner’s Toll, 2010” was released by McFarland Publishing. You can reach him at www.mattmangino.com and follow him on Twitter at @MatthewTMangino.

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Drug, Alcohol, Suicide Deaths in U.S. Highest Since 1999

According to The Crime Report, the number of deaths from alcohol, drugs and suicide in 2017 hit the highest level since the collection of federal mortality data started in 1999, according to an analysis by two public health nonprofits, the Trust for America’s Health and the Well Being Trust reported by the New York Times. The two groups parsed the latest data from the federal Centers for Disease Control and Prevention.  More than 150,000 Americans died from alcohol and drug-induced fatalities and suicide in 2017. Nearly a third — 47,173 — were suicides. The grim statistics are fueled by synthetic opioid deaths. Twenty years ago, fewer than 1,000 deaths a year were attributed to fentanyl and synthetic opioids. In 2017, more than 1,000 Americans died from synthetic opioid overdoses every two weeks, topping 28,000 for the year. Most of the increase occurred in the preceding five years, when such deaths rose tenfold and the opioid epidemic became the leading cause of death for Americans under 55.

West Virginia and New Mexico had the highest number of deaths, the analysis showed, with Mississippi and Texas the lowest. By region, the Northeast had the highest opioid death rates followed by the Midwest. The South’s rate was nearly half that of the Northeast. John Auerbach of Trust for America’s Health said that though doctors and drug companies have been taking steps to control opioid addictions, patients who are addicted to prescription opioids often shift to synthetic ones, like fentanyl, which is 50 times more potent than heroin. Fentanyl has also snaked its way into other drugs like cocaine, Xanax and MDMA, widening the epidemic. Suicides by gun increased 22 percent over the last decade. Guns were used in nearly half of the nation’s 47,173 suicides in 2017.

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Ohio doctor behind 28 overdose deaths

Troy Allison received a 1,000 microgram dose of fentanyl, which is used in hospitals to treat severe pain, although typically in much smaller amounts, reported NBC News.

Troy Allison's death and at least 33 others involving Mount Carmel patients from 2015 to 2018 remain part of a wider internal investigation into Dr. William Husel, who treated them, and why the intensive care doctor allegedly ordered "significantly excessive and potentially fatal" doses of pain medication in 28 of the cases, according to the hospital.

Husel's medical license was suspended Friday by the State Medical Board of Ohio, which said the allegations against him were so serious that he was not afforded a hearing prior to the board's vote and can no longer practice medicine in the state.

Yet, key questions remain unanswered: Why such high doses, and were they the result of repeated mistakes — or intentionally meant to be deadly?

Doctors, pharmacists and lawyers who spoke with NBC News say hospitals such as Mount Carmel, one of the largest health systems in Ohio, have multiple safeguards in place that should prevent patients from being overmedicated to death. There are checks and balances allowing those in the chain of command to trigger an alarm, the medical experts added, so that an error can be avoided or reviewed after the fact, including during emergency situations in which dangerous drugs such as fentanyl are used.Related

"We know that the risk for error goes up in chaotic situations, but hospitals have worked hard to limit these risks and do a very good job protecting safety in fast-paced environments like the emergency room or intensive care unit," said Dr. Daniel Tobin, an associate professor of medicine at Yale University and a leading expert on opioid safety.

At least six wrongful death lawsuits have been filed on behalf of deceased patients, including Troy Allison, alleging Husel ordered the doses either negligently or purposefully in order to hasten the end of their lives.

All Christine Allison knows is that her husband of 11 years, her best friend and a father of two, was taken from her — and she wants Husel to explain why.

"He actually seemed very kind and very compassionate. I trusted him," she said of the doctor. "Now I think he needs to be in prison. The system failed."

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PLW: Term 'Perpetrator' Weighs Heavily in Drug-Using Mom-To-Be Abuse Decision

Matthew T. Mangino

The Legal Intelligencer

January 10, 2019

The Pennsylvania Supreme Court ruled that a mother who used opioids and marijuana during her pregnancy cannot commit child abuse under the Child Protective Service Act (CPSL), 23 Pa.C.S.A. 6301.

A divided Pennsylvania Supreme Court issued its opinion interpreting the CPSL on Dec. 28.

The case involved a newborn girl who spent 19 days in the hospital, being treated for drug dependence that caused severe withdrawal symptoms. Two weeks before the girl was born the mother, known as A.A.R., tested positive for opiates, marijuana and benzodiazepines.

The decision comes in the shadow of an opioid crisis in this country. The latest statistics show Pennsylvania leading the nation in fatal overdoses, with about 5,400 in 2017.

In fact, the opinion in In the Interest of L.J.B., No. J-57-2018 authored by Justice Christine Donohue acknowledged in a footnote that Gov. Tom Wolf took the unprecedented step of proclaiming the heroin and opioid epidemic a statewide disaster emergency.

According to Reuters, opioid abuse among pregnant women affected 6.5 out of every 1,000 delivery hospitalizations in 2014, up from 1.5 per 1,000 in 1999, as tracked by the U.S. Centers for Disease Control and Prevention.

In this case, A.A.R. was in jail. She was released and relapsed into drug use, before she learned she was pregnant. She sought treatment for her addiction but relapsed again.

L.J.B. was born on Jan. 27, 2017. According to Donohue’s opinion, the child immediately displayed signs of neonatal abstinence syndrome. Clinton County Children and Youth Social Services took L.J.B. into emergency protective custody after her birth, and accused A.A.R. of child abuse.

The Juvenile Court ruled that L.B.J. was a dependent pursuant to the CPSL but conducted a separate hearing to determine if A.A.R.’s drug use while pregnant was child abuse.

The Juvenile Court held that Children and Youth Services “cannot establish child abuse in this matter on the actions committed by mother while child was in fetus.”

The Superior Court reversed agreeing that the CPSL does not include abuse of a fetus or unborn child, but concluded that the “Mother’s drug use is a recent act or failure to act under 6303 (b.1) and (5) of the CPSL.”

The Supreme Court took the case as a matter of first impression.

This is not a criminal matter. Pennsylvania law already makes clear that mothers cannot be prosecuted for harming their fetuses.

Crimes against the Unborn Child Act, 18 Pa.C.S.A. 2601 makes it a crime to injure or kill an unborn child. However, the law also establishes three exceptions: it cannot be used to prosecute people who perform legal abortions, medical personnel or pregnant women for harming their own unborn children.

According to the Pittsburgh Post-Gazette, when legislators were debating the bill before it became law in 1997, opponents worried it would lead to the prosecution of pregnant women—but supporters said that could not happen because of the protection written into the law. The law has been used regularly when a pregnant woman’s unborn child is injured or killed by a third party.

“These statutes are not intended to prosecute pregnant women, as you can clearly see from the way the statute is written,” Sara Rose, staff attorney for the American Civil Liberties Union of Pennsylvania, told the Post-Gazette in 2017 when prosecutors in Butler County sought to prosecute a pregnant woman under the statute. “I don’t see, based on the plain language of the statute, how you can charge a pregnant woman.”

At issue was whether Kasey Rose Dischman could be convicted of aggravated assault of her unborn child for overdosing in June 2017 when she was 30 weeks into her pregnancy. Dischman went into cardiac arrest and her child had to be delivered prematurely.

Butler County Judge William R. Shaffer dismissed that charge after finding that, although Dischman is accused of committing a “senseless, selfish and heinous act,” the law does not allow the aggravated assault count to be applied in cases where the victim is the mother’s own unborn child.

The district attorney appealed to the Superior Court.

Superior Court Judge Carolyn H. Nichols concluded that Pennsylvania does not criminalize the prenatal acts of mothers-to-be. As a result, a pregnant woman who overdoses on illegal drugs cannot be prosecuted for assaulting her unborn child.

In A.A.R.’s appeal the definitions as set forth by the legislature in the CPSL are crucial. Unlike the Crimes Against the Unborn Child Act, 18 Pa.C.S.A.2601 as read in conjunction with the Abortion Control Act 18 Pa.C.S.A., 3220 the CPSL does not include a fetus or unborn child in its definition of “child.”

A child is defined as any person under the age of 18. The CPSL defines “child abuse” as “intentionally, knowingly or recklessly … causing bodily injury to a child through any recent act or failure to act.” A “perpetrator” of child abuse is defined as—for purposes of this case—a parent of a child, 23 Pa.C.S.A. 6306 (a) (1).

The Supreme Court zeroed in on the definition of “perpetrator.” L.J.B.’s mother contended that pursuant to the clear language of CPSL, she did not commit “child abuse” while she was pregnant because there was no “child,” and she therefore was not a “perpetrator.”

A “perpetrator” is “a person who has committed child abuse under the CPSL,” 23 Pa.C.S.A. 6303 (a). As the parties in this case agreed, the CSPL’s definition of a “child” does not include a fetus or an unborn child.

Although A.A.R. used illegal drugs while pregnant that caused bodily injury to L.J.B. she was not a perpetrator of child abuse. A.A.R. was not yet a parent and A.J. B. was not yet a child.

As a result, according to the Pennsylvania Supreme Court, a mother cannot be found to have committed child abuse against a child based on her illegal drug use while pregnant because she was not a perpetrator at the time of the drug use.

Matthew T. Mangino is of counsel with Luxenberg, Garbett, Kelly & George. His book “The Executioner’s Toll,” 2010 was released by McFarland Publishing. You can reach him at www.mattmangino.com and follow him on Twitter @MatthewTMangino
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Trump signs measure to fight opioid epidemic

US President Donald Trump signed the SUPPORT for Patients and Communities Act into law, a measure to combat the opioid crisis by reducing drug demand through education, awareness and prevention efforts, enhancing treatment and recovery, and cutting off the supply from traffickers, reported Jurist.

The act has been deemed “the single largest legislative package addressing a single drug crisis in history.” SUPPORT is the short name for “Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment.” Trump’s administration is partnered with the National Drug Control Policy (ONDCP), Truth Initiative and Ad Council to focus the education toward youth and young adults.

In preventing opioid addiction, the act induces research aimed at “efforts for innovative therapies to prevent addiction, to offer non-addictive pain management alternatives, and to improve overdose prevention tools.” Among other actions to eliminate drug trafficking, the act will help to protect the borders, ports of entry, and waterways and “require more advanced data to flag high-risk international mail shipments.” Other provisions address establishing measures to curtail shipments of synthetic opioids like fentanyl, funding research into non-addictive painkillers, and requirements for the Food and Drug Administration to allot smaller amounts of prescription opioid pills.

The Senate voted 99-1 to pass the bill last month with Senator Mike Lee (R-UT) giving the only vote against the legislation.

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The Vindicator: Ohio on right track with justice reform

Matthew T. Mangino

The Youngstown Vindicator

July 15, 2018

When crime rises, the first inclination of lawmakers is punishment. Longer sentences, mandatory minimums and extended periods of supervision all add to the cost of the criminal justice system with little impact on the rate of recidivism.

For politicians, that’s a tough sale to the public. Trying to convince taxpayers that it’s more prudent and cost effective to invest in rehabilitation rather than punishment can cost a lawmaker his job.

Ohio is in a position to proceed with meaningful sentence reform without waiting on politicians to act. A bipartisan coalition of community, law enforcement, faith and business leaders has proposed a ballot measure for November to reduce penalties for nonviolent drug offenders.

Signatures

Supporters of the “Neighborhood Safety, Drug Treatment and Rehabilitation” amendment submitted 730,031 signatures recently to the various county election boards. The Ohio Secretary of State has until July 24 to certify or reject signatures. To qualify for the ballot, 305,591 valid signatures of Ohio registered voters are needed.

The reform initiative comes at a time when Ohio is in the midst of one of the nation’s most lethal periods of drug abuse. Ohio’s drug overdose deaths rose 39 percent – the third-largest increase nationwide – between mid-2016 and mid-2017, according to figures released earlier this year by the federal government.

The state’s opioid crisis continued to explode in the first half of last year, with 5,232 Ohio overdose deaths recorded in the 12 months ending June 30, 2017, according to the Centers for Disease Control and Prevention.

Just across the border, Pennsylvania saw the largest increase in overdose deaths during that same period.

The escalation of drug deaths in Ohio was nearly three times the 14.4 percent increase in deaths nationally, which grew to about 67,000 across the U.S., according to government estimates.

In Columbus, Franklin County Coroner Anahi Ortiz said that the more recent estimates are even more grim.

“Compare the first three quarters of 2017 to the first three quarters of 2016,” Ortiz told the Columbus Dispatch. “So, an actual comparison day by day – we’ve already seen a 57 percent increase.”

Fentanyl is what’s mostly spurring the additional deaths, officials said. The synthetic opiate has been cut into the heroin supply and, in some cases, replaced heroin that’s sold on the streets, reported the Cincinnati Enquirer.

Fentanyl is more deadly because it’s about 50 percent stronger than heroin and is being altered to create a more potent fentanyl, according to the federal Drug Enforcement Administration.

Ohio’s reform initiative is risky. It is a long-term investment when people are looking for an immediate fix. Money saved from those affected by the amendment would be diverted to substance-abuse programs and to crime victims’ services.

Under the drug treatment and rehabilitation amendment, possessing, obtaining or using a drug or drug paraphernalia would be a misdemeanor offense, with a maximum punishment of 180 days in jail and $1,000 fine. First and second offenses within a two-year period could only be punished with probation. The amendment would not apply to drug dealers.

Half-day credit

Convicted individuals could receive a half-day credit against their sentence for each day of rehabilitative work or programming, up to 25 percent of the total sentence.

An individual on probation for a felony would not be sent to prison for a non-violent violation of probation.

The question facing policy makers: Is public safety better served by incarcerating drug offenders, or would drug treatment and prevention programs be more efficient and effective at curbing drug abuse and promoting public safety?

According to the Justice Policy Institute, studies by the nation’s leading criminal justice research agencies have shown that drug treatment, in concert with other services and programs, is a more cost effective way to deal with drug offenders.

Ohio appears to be on the right track.

Matthew T. Mangino is of counsel with Luxenberg, Garbett, Kelly & George P.C. His book “The Executioner’s Toll, 2010” was released by McFarland Publishing. You can reach him at www.mattmangino.com and follow him on Twitter @MatthewTMangino.

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New Report: Access to overdose reversing Naloxone increases riskier behavior

New research by Jennifer L. Dolec of the University of Virginia and Anita Mukherjee of the University of Wisconsin explores the moral hazard of the overdose reversing drug Naloxone.

According to the abstract, the United States is experiencing an epidemic of opioid abuse. In response, many states have increased access to Naloxone, a drug that can save lives when administered during an overdose. However, Naloxone access may unintentionally increase opioid abuse through two channels: 

(1) saving the lives of active drug users, who survive to continue abusing opioids, and 

(2) reducing the risk of death per use, thereby making riskier opioid use more appealing. 

By increasing the number of opioid abusers who need to fund their drug purchases, Naloxone access laws may also increase theft. We exploit the staggered timing of Naloxone access laws to estimate the total effects of these laws. We find that broadening Naloxone access led to more opioid-related emergency room visits and more opioid-related theft, with no reduction in opioid-related mortality.

These effects are driven by urban areas and vary by region. We find the most detrimental effects in the Midwest, including a 14% increase in opioid-related mortality in that region. We also find suggestive evidence that broadening Naloxone access increased the use of fentanyl, a particularly potent opioid. While Naloxone has great potential as a harm-reduction strategy, our analysis is consistent with the hypothesis that broadening access to Naloxone encourages riskier behaviors with respect to opioid abuse.

The Crime Report: W. Va., Ohio Lead Nation in Drug Overdose Death Rates

Drug overdoses killed 4,329 Ohioans in 2016, the second-highest death rate in the nation, reported The Crime Report. That’s up 24 percent over the 3,310 drug deaths the previous year, according to a report released Thursday by the federal government, reports the Columbus Dispatch. Despite increased government spending, Ohio’s rate of drug-overdose deaths, 39.1 per 100,000 people, trailed only West Virginia’s 52 per 100,000 population. 

The powerful and deadly synthetic opioid fentanyl is largely to blame for the exploding number of deaths, according the National Centers for Health Statistics. “We’ve got a big problem in Ohio,” said Dublin Police Chief Heinz von Eckartsberg. First responders in Dublin had to use two doses of the drug antidote naloxone to revive a 20-year-old man earlier this week and 11 doses to revive another man last month, suggesting they’d taken fentanyl. Statewide, emergency responders have administered more than 43,000 doses of naloxone this year, up from 31,800 in all of 2016.

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GateHouse: Word of the demise of ‘the great American crime decline’ premature

Matthew T. Mangino

GateHouse Media

November 17, 2017

The National Institute of Justice reported this week that homicides in America’s largest cities rose in 2015 and again in 2016, although not all cities experienced a significant increase and some cities even experienced a decline.

In 2016, the FBI Uniform Crime Report found that there were 17,250 homicides nationwide. That is an increase of 8.6 percent from 2015 on top of a 12.1 percent increase from 2014-2015.

That adds up to about a 21 percent increase in homicide over two years, which is the largest two-year increase in a quarter of a century.

The National Institute of Justice considered two explanations for the increase:

- The heroin and opioid epidemic
- The so-called “Ferguson effect,” named for the city outside of St. Louis where the police response to unrest has impacted policing nationwide.

The larger increases in drug-related homicides as compared to other types of homicide provided researchers with preliminary evidence that expansions in the illegal drug trade contributed to increase in homicide.

The current drug epidemic is disproportionately concentrated in the white population, and homicides have increased among whites as well as among African Americans and Hispanics. The report concluded that the drug epidemic may have had an especially strong influence on the rise in homicide rates among whites.

The second explanation put forth by researchers is the Ferguson effect, which resulted in “de-policing, compromised police legitimacy, or both.”

Surveys of police reveal widespread concerns about increased police-community tensions and reductions in proactive policing in the aftermath of widely publicized deadly encounters between the police and African Americans.

Increases in homicide followed decreases in arrests in Baltimore and Chicago, although it is not known whether the same was true in other cities.

Alienation from the police can result in a decreased willingness to call the police or to cooperate with them and, some studies suggest, an increase in criminal behavior.

The National Institute of Justice concedes that “current evidence that links de-policing to the homicide rise is mixed, at best,” and that it remains an “open research question.”

The homicide increase in the United States is relatively large, if not unprecedented, especially in several of the nation’s biggest cities. Because it arrived on the heels of a long-term crime drop, it is reasonable to ask whether the current homicide spike marks the end of what has been referred to by Professor Franklin E. Zimring of the UC Berkeley School of Law as the “the great American crime decline.”

Before we break into a panic, a review of the data seems to indicate the answer is no. The national homicide rate was more than 35 percent lower in 2016 than in 1995 and the homicide rate in big cities was about 46 percent lower. According to the National Institute of Justice, even at the elevated rates of increase in 2015 and 2016, it would take about five years for the national homicide rates to return to the levels of the early 1990s.

However, it is difficult to ignore the increase in homicides as well as the ongoing plight of minority members of our communities. For instance, the leading cause of death for young African American men is homicide, and it causes more deaths than the other top nine causes of death put together.

Professor David Kennedy of the John Jay College of Criminal Justice said recently, ”[W]e’re debating these small changes and the national homicide rate had come down to between four and five per 100,000 and is now edging back up toward five. There are communities all over the country where especially young men of color are experiencing persistent homicide rates of over 500 per 100,000 year after year after year after year.”

-- Matthew T. Mangino is of counsel with Luxenberg, Garbett, Kelly & George P.C. His book “The Executioner’s Toll, 2010” was released by McFarland Publishing. You can reach him at www.mattmangino.com and follow him on Twitter @MatthewTMangino.

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Portugal halts opioid crisis with decriminalization

In 2001, Portugal became the first country to completely decriminalize the consumption of all illicit substances, reported Amherst College's The Common. Rather than being arrested, those caught with a personal supply might be given a warning, assessed a small fine, or sent to have a chat with a local dissuasion commission—a doctor, a lawyer, and a social worker—about treatment, harm reduction, and support services available to them.

A bold stance was taken, an opioid crisis stabilized, and the ensuing years saw dramatic drops in problematic drug use, HIV and hepatitis infection rates, overdose deaths, drug-related crime, and incarceration rates. HIV infection rates, for example, plummeted from an all-time high in 2000 of 104.2 new cases per million to 4.2 cases per million in 2015. The data from what is now a decade and a half of largely positive results have been studied and held up as example, and have given weight to harm-reduction movements around the globe. It’s misleading, however, to credit these positive results entirely to a change in law.

Portugal’s remarkable recovery, and the fact that it has held steady through several changes in government—including conservative leaders who would have rather ushered in a return of the War on Drugs—could not have happened without an enormous cultural shift and collective change of heart around how the country viewed drugs, addiction, and itself. In many ways, the law was merely a reflection of transformations that were already happening in clinics, in pharmacies, and around kitchen tables across the country.

Decriminalization as an official policy allowed for the pooled support and interconnection of a broad range of health, psychological, employment, housing, social, and cultural services that were already grasping to work together to serve their communities, like in Olhão. The language people used began to shift, too. Those who were referred to sneeringly as “drogados”—“junkies”—became known more broadly, more sympathetically, and more accurately as “people who use drugs” or “people with addiction disorders.” This, too, was crucial.

Portugal’s story also serves as a warning bell.

The Portuguese opioid addiction epidemic was contained, not made to disappear. The consequences of the eighties and nineties weigh heavily today, as the oldest generation of chronic users and ex-users grapple with complications that include hepatitis C, cirrhosis, and liver cancer. The long-term costs of problematic drug use are a burden on a public healthcare service that is still struggling to recover from a recession filled with cutbacks.

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GateHouse: America’s opioid crisis a ‘national emergency’

Matthew T. Mangino

GateHouse Media

November 3, 2017

Last week, President Donald Trump directed the Department of Health and Human Services to declare the opioid crisis a public health emergency. According to The Associated Press, the opioid epidemic is the most widespread and deadly drug crisis in American history.

Opioids are manmade drugs created to reduce pain, and in some instances, to curtail addiction. Opioids include both legal painkillers like morphine and oxycodone and addiction treatment drugs like methadone. In addition, opioids include illegal drugs such as heroin.

To put the crisis into perspective consider this, the National Center for Health Statistics in 2016 reported there were more 64,000 overdose deaths in the United States—76 percent involved opioids. That is an average of 134 opioid overdose deaths a day.

Drug overdoses already kill more Americans than car crashes and, in a grim milestone, more people died from heroin-related causes than from gun homicides in 2015. As recently as 2007, gun homicides outnumbered heroin deaths by more than 5 to 1, reported the Washington Post.

No place has experienced the suffering of opioid addiction more than West Virginia. The Charleston Gazette-Mail analyzed shipment data from the U.S. Food and Drug Administration and found that 423 million opioid painkillers were delivered to West Virginia between 2007 and 2012.

In Kermit, West Virginia, population 392, drug companies shipped nearly 9 million opioid pills over 2 years to a single pharmacy, reported the Post.

Trump said, “This epidemic is a national health emergency . . . No part of our society—not young or old, rich or poor, urban or rural—has been spared this plague of drug addiction and this horrible, horrible situation that’s taken place with opioids.”

In fact, the opioid crisis is so far-reaching that it has had an impact on life expectancy in this country. While overdose deaths in general in the U.S. more than doubled in 15-years, opioid overdoses more than tripled, revealed a study from the Centers for Disease Control. The study found that the average American’s life expectancy grew from 2000 to 2015. In 2016, the opioid crisis and related overdoses have shaved 2.5 months off that number.

This week, the President’s Commission on Combating Drug Addiction and the Opioid Crisis recommended a national media campaign to encourage opioid addicts to seek help. Only 10.6 percent of people who need treatment get it, the report noted.

The media campaign would encourage addicts to “stop being afraid or ashamed of seeking help when facing their addiction.”

The commission also suggests expansion of drug courts, in which addicts convicted of nonviolent offenses are diverted into programs that combine treatment with mandatory drug testing and court appearances. The commission said drug courts, which are currently offered in just 44 percent of U.S. counties, should embrace medication-assisted treatment to improve outcomes.

The president touched on a media campaign when he announced that the opioid crisis is a national emergency. Trump said the government would produce “really tough, really big, really great advertising” aimed at persuading Americans not to start using opioids in the first place. The New York Times suggests that Trump is seemingly harking back to the “Just Say No” antidrug campaign led by Nancy Reagan in the 1980s.

“This was an idea that I had, where if we can teach young people not to take drugs,” Trump said, “it’s really, really easy not to take them.”

What was absent from the president’s declaration and the commission’s report was resources. The commission made recommendations regarding the distribution of existing federal funds, but made no demand for additional funding.

Practitioners on the frontline fighting addiction are concerned that the proposals are meaningless without dedicating resources for implementation. The concern is amplified when the commission talks of reshuffling existing funding at the expense of existing programs.

Matthew T. Mangino is of counsel with Luxenberg, Garbett, Kelly & George P.C. His book “The Executioner’s Toll, 2010” was released by McFarland Publishing. You can reach him at www.mattmangino.com and follow him on Twitter at @MatthewTMangino.

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Opioid epidemic frightening but not unprecedented

The opioid epidemic is the most widespread and deadly drug crisis in the nation’s history. But there has been a long string of other such epidemics, each sharing chilling similarities with today’s unfolding tragedy, reported The Associated Press.

There was an outbreak after the Civil War when soldiers and others became addicted to a new pharmaceutical called morphine, one of the first of many man-made opioids. There was another in the early 1900s after a different drug was developed to help “cure” morphine addiction. It was called heroin.

Cocaine was also developed by drugmakers and sold to help morphine addiction. It cleared nasal passages, too, and became the official remedy of the Hay Fever Association. In 1910, President William H. Taft told Congress that cocaine was the most serious drug problem the nation had ever faced.

Over the next century, abuse outbreaks of cocaine, heroin, and other drugs like methamphetamine, marketed as a diet drug, would emerge and then fall back.

Alcohol and cigarettes were — and remain — the nation’s primary addictions. Both kill far more people than drugs. But since the middle of the century, there’s been wave after wave of other drug abuse outbreaks.

Amphetamines, developed in the 1930s, took off in the 1950s. Marketed by drug companies and promoted by doctors, they were used for weight loss, anxiety and depression. Methamphetamine, developed by the Burroughs Wellcome drug company, was often prescribed as a diet pill and abused by those attracted by the surge of energy it produced. Users who injected it were known as “speed freaks.”

Like the heroin surge before it, crack was seen as tied to urban blight and violent crime. This triggered a new drug war, including the “this is your brain on drugs” TV spots that showed frying eggs, and harsh jail sentences for the sale and possession of crack that were far more severe than the penalties for regular cocaine.

The crack epidemic died out in the 1990s, tailing off at roughly the same time both in cities that aggressively arrested people and cities that didn’t. Experts said the police crackdown contributed, but more important was society’s growing repulsion to the drugs. Families and communities were shattered by crack-related murders and arrests. The drug’s users came to be regarded as disgraceful “crackheads.” Even risk-taking kids, looking for new highs, started to avoid crack.

Health officials are fighting the opioid epidemic on three fronts: Preventing overdose deaths, helping people recover from addiction, and preventing new addictions.

There appears to be some success on the first front. The number of new addictions may be receding.

A recent federal report noted a downward trend in “opioid misuse” in adults younger than 50. Prescription rates are falling, though they remain far higher than years ago. And according to a closely watched University of Michigan study of adolescents, use of the opioids OxyContin and Vicodin has been low and falling for several years. In 2016, heroin use was the lowest in the survey’s 41-year history.

“I suspect we may be past the peak (of the epidemic), at least in terms of initiation,” said Jonathan Caulkins, a drug policy scholar at Carnegie Mellon University.

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A “mass casualty event” played out in slow motion

Opioids are killing more than 50,000 Americans a year, far more than the toll of the AIDS epidemic at its height, reported the Guardian.

President Trump is set to declare the opioid crisis a “national emergency,” reported the Washington Post. Trump telegraphed this when he recently told reporters that he would soon have a “major announcement” on the “massive opioid problem,” and people inside the White House are now leaking word that this announcement will herald an all-hands-on-deck push to combat the epidemic.

But members of Trump’s own handpicked commission to combat the epidemic aren’t nearly as confident, I’m told. They are increasingly worried that the Trump administration will not actually follow through with a robust response, even if he does go before the cameras and declare the crisis a national emergency, and they are increasingly annoyed by the efforts of people inside the administration who are resistant to such a response, one member of the commission says.

In a surprisingly blunt interview with me, Patrick Kennedy, the former congressman from Rhode Island who is a member of the President’s Commission on Combating Drug Addiction and the Opioid Crisis, candidly described the mood on the commission as one racked by pessimism about the president’s willingness and ability to follow through with a response that matches the scale of the human disaster that has unfolded.

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Beaver County, Pennsylvania sues opioid manufactures

Pennsylvania's Beaver County filed a lawsuit on against opioid manufacturers, reported Jurist.

The lawsuit, filed in the Beaver County Court of Common Pleas [official website], accuses manufacturers and doctors of deceptive acts, fraud, unjust enrichment, negligence, misrepresentation and public nuisance, seeking in return compensatory damages, punitive damages and the county's legal costs.

The complaint describes the state of the opioid epidemic in Beaver County, noting it spends millions annually in response to the opioid crisis, including expenses for emergency responses, police overtime, and increased incarceration and treatment. The first 10 pages of the 83-page complaint set forth support for the county's claim, citing to national and county-wide opioid-related statistics. According to the complaint, deaths associated with opioid use have tripled in Beaver County from 1999 to 2015, causing it to incur the highest rate of fatal overdoses in Pennsylvania in 2017 at 59.9 per 100,000 people.

The majority of the text concentrates on manufacturers' alleged strategy and tactics which caused and continue to cause addiction, illness, and death to users. As described in other similar lawsuits, these plaintiffs accuse manufacturers of promoting the sale and use of opioids through third-parties, many of whom are doctors:

Recognizing that doctors are gatekeepers for controlling access to prescription drugs, not surprisingly, manufacturers focused the bulk of their marketing efforts ... on the professional medical community. As a controlled substance with significant regulatory barriers limiting access, Defendants knew doctors would not prescribe opioids to patients with common chronic pain complaints unless doctors were convinced that opioids had real benefits and minimal risks. Accordingly, Defendants concealed from prescribers, patients, and the public that evidence in support of their promotional claims was inconclusive, non-existent and unavailable. Instead, each Defendant disseminated misleading and unsupported messages that caused the target audience to believe those messages were corroborated by scientific evidence. As a result, Beaver County doctors began prescribing opioids long-term to treat chronic pain—a treatment choice that most if not all never would have considered prioir to Defendants' campaign.

Named defendants in the lawsuit include four allied physicians, and manufacturers and some subsidiaries of Purdue Pharma, Teva Pharmaceuticals, Cephalon, Johnson & Johnson, Janssen Pharmaceuticals, Endo Health Solutions, Allergan, Actavis, Watson Pharmaceuticals, McKesson, Cardinal Health, AmerisourceBergen.

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Opioid crisis is impacting life expectancy in the U.S.

This week, the Centers for Disease Control and Prevention published an analysis showing the opioid crisis has actually negatively impacted life expectancy in the U. S.  The analysis, published in the Journal of the American Medical Association, crunched the numbers recorded by the National Vital Statistics System Mortality file, a storehouse of death data from all 50 states and the District of Columbia, from between 2000 to 2015.

According to the Washington Post, the analysis found that the average American’s life expectancy grew overall from 2000 to 2015, but that the astounding rise in opioid-related deaths shaved 2.5 months off this improvement. That’s .21 years, compared to the .02 years taken off the average life expectancy by alcohol overdoses.

No factor negatively affected life expectancy more. “It really underlines how serious the problem of opioid overdose has become in the U.S.,” the CDC’s Deborah Dowell told Time. “In general we don’t see decreases in life expectancy attributable to a single cause that are of this magnitude.” While overdose deaths in general in the U.S. more than doubled in that 15-year span, opioid overdoses more than tripled, the study reported. The average life expectancy for an American born in 2010 was 76.8 years, which grew to 78.8 years in 2015. The study suggested that but for opioid-related deaths, it would have been higher still.

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Vox: How America became the world’s leading opioid prescriber

So how did the US become the world’s top prescriber of opioid painkillers? There are several reasons, according to Vox.

First, there were the pharmaceutical companies. Wanting to make as much money as possible, these companies marketed their drugs as safe and effective for treating pain — even though the evidence for opioids shows that, particularly for chronic pain, the risksoutweigh the benefits in most, but not all, cases. Many doctors and patients were convinced by this campaign. (Purdue Pharma, the maker of OxyContin, and some of its higher-ups later paid more than $600 million in fines for their misleading marketing claims, and opioid makers and distributors are now facing many more lawsuits on similar grounds.)

Then there were doctors. On one hand, doctors were under a lot of pressure from advocacy groups (some pharma-backed), medical associations, and government agencies to treat pain more seriously. On the other hand, doctors faced increasing pressure to see and treat patients quickly and efficiently.

The latter is a result of what Stanford addiction specialist Anna Lembke, author of Drug Dealer, MD, describes as “the Toyotazation of medicine — tremendous pressure on doctors within these large integrated health care centers to practice medicine in a certain way and get patients out in a timely fashion to be able to bill insurers at the highest possible level and to make sure that their patients were satisfied customers.”

Opioids provided an answer to these two problems. Doctors didn’t know how to deal with many of the complex pain problems their patients were dealing with, because in many cases the answers were complicated and simply required too many resources and too much time. So an easy response was to give patients some pills.

In many situations, doctors simply prescribed far too much. With acute pain patients, doctors often gave weeks- or even months-long prescriptions when only a few days’ worth was needed. It was common, for example, to give weeks-long supply for opioids after wisdom teeth removals, even though the procedure usually leads to pain for no more than a week and the pain typically can be treated with milder painkillers like ibuprofen. The prescriptions left patients with a lot of extra pills, all because a doctor wanted to play it safe — and make sure that a patient didn’t come back complaining that a provider gave too few pills the first time around.

And in other cases, the doctors involved were outright malicious — establishing “pill mills” in which they gave away opioids with little scrutiny, often for hard cash.

On the patient side, there were serious medical issues that needed to be addressed. For one, the Institute of Medicine has estimated that about 100 million US adults suffer from chronic pain. Given that the evidence shows opioids pose more risks than benefits in the majority of these cases, patients likely should obtain other treatments for chronic pain, such as non-opioid medications, special physical exercises, alternative medicine approaches (such as acupuncture and meditation), and techniques for how to self-manage and mitigate pain.

With the broader proliferation of opioids, there were so many of these pills — enough prescribed just in 2015 to medicate every American around the clock for three weeks, according to the Centers for Disease Control and Prevention (CDC) — that they were often diverted.

So America got its deadliest drug overdose crisis ever.

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