As the opioid addiction crisis in America continues to put pressure on numerous states, one of the biggest questions that has emerged is regarding who exactly is responsible for such a dramatic shift in American drug consumption habits. Many point to an increase in the number of prescriptions doled out as part of pain management regimens by doctors, and lawsuits have followed accordingly. The targets of those lawsuits, however, have tended to be the pharmaceutical companies that developed many of the opioids currently used by patients.
One such case has arisen in the state of Indiana, and the state’s attorney general has pointed the finger directly at Purdue Pharma. The claim made by the state of Indiana is that drugs manufactured by Purdue Pharma, a company based in Connecticut that has no association with the state’s renowned Purdue University, account for 54 percent of the prescriptions written for residents of the state since 2012. The state-level lawsuit is joined by a number of cities and counties from all over Indiana, and it mirrors similar ones that have been filed in other states and before the federal court system.
The History of Purdue Pharma and OxyContin
Purdue Pharma is a company that’s known for manufacturing a variety of drugs, including opioids. Among the brand-name opioid products the company has sold are:
As far back as 2007, the company has been the subject of claims that it misled regulators, doctors and patients about the addiction and substance use disorder risks associated with OxyContin. In 2007, the company agreed to pay more than $600 million as fines and additional payments in relation to both criminal and civil allegations that it misbranded the drug.
Released to the market in 1996, OxyContin was treated as the long-awaited opioid that doctors had dreamed of. The company told doctors and patients that it utilized a time-release formula that presented a diminished risk of abuse compared to other known strong painkillers such as Percocet or Vicodin. It was also claimed that OxyContin didn’t produce the same high that other opioids generated in the human body. The drug was marketed very aggressively, and within four years, the company was raking in sales of more than $1 billion.
Two things quickly made it apparent that OxyContin was dangerous: Street-level drug users and everyday patients learned that chewing, crushing or snorting the tablets produced a high as strong as heroin. In addition, pharmaceutical representatives marketed the drug directly to general practitioners who often had little or no substance abuse counseling training.
By the year 2000, sections of America that had never seen heavy drug use problems in their populations were suddenly being overwhelmed with trafficking in OxyContin, pharmacy break-ins and drug-related crimes.
The Scale of Indiana’s Opioid Crisis
The rate of opioid-related deaths in the state of Indiana from 1999 to 2016 skyrocketed, going from 0.8 deaths per 100,000 residents to 12.6 per 100,000. Nationally, 13.3 deaths per 100,000 people occurred in 2016. Historically, Indiana has always been below the national average in such deaths, but it’s now closer than it has ever been to exceeding the U.S. at large. In fact, the rate went up nearly 50 percent in just one year, rising from 8.5 deaths per 100,000 in 2015 to 12.6 in 2016. At the same time, the total number of opioid-related overdose deaths also shot up, reaching 794 in 2016 after being close to zero in 1999.
Intravenous drug use has also been tied to an increase in HIV cases in the state. In 2015, 8.2 percent of new male cases and 13.2 percent of new female cases of HIV could be attributed to IDU behaviors. OxyContin can be broken down and used by injecting it into the bloodstream. Chronic Hepatitis C cases in have risen alongside IDU issues. During one outbreak in Scott County, 97.1 percent of co-infected cases were attributable to IDU.
One study published by Indiana University researchers indicated that the direct loss in the state’s gross domestic product due to the opioid crisis represented $1.5 billion per year. That represents nearly 0.5 percent of the state’s GDP from 2016. Indirect economic costs that can’t be accurately calculated likely also arise from:
- Stigma and reputation effects on the employability of individuals with substance use disorders
- Morbidity effects
- Breakdowns in service efficiency among state businesses
As the unemployment rate continues to improve in the decade following the Great Recession, there are huge questions about the economic effects of members of the population not being considered employable due to untreated substance abuse issues.
It’s estimated that 11.9 percent of opioid users in the Hoosier State are considered unemployed, meaning they want work but cannot find it. A further 30.6 percent of them are considered non-employed, meaning they are not presently seeking work or have been unemployed for so long that they’ve exhausted all possible benefits. Tallied up, 42.5 percent of the opioid-using population is not part of the workforce. Across the country, 25 percent of job applicants failed at least one drug test in 2017.
The state’s overall prescription rate of opioids peaked in 2012 and has since dropped. Unfortunately, Indiana is still ranked 11th in the country out of 50 states for its per-capita rate of opioid prescriptions issued by doctors.
Attempts at Mitigating the Crisis
In order to try to get the growth of the problem under control, the state has implemented rules that require doctors to only provide a seven-day supply of opioids to first-time users and anyone under the age of 18.
While such measures seem to have curbed the rate of deaths from prescription opioids, they also may have had an unintended consequence. Just as prescription-related deaths started to drop in the state, heroin-related deaths shot up at a rate even faster than the reduction. This suggests that many individuals exposed to opioids by their doctors may have simply bypassed the system and gone straight to street-level drug dealers to get their fixes.
Aging Into Trouble
A major concern about the state is that its population may be following a counterintuitive pattern. People historically think of age cohorts as aging out of drug-related trouble, meaning that most teenagers get criminal habits out of their systems as they grow into their 20s and 30s. Unfortunately, given the strong connection between pain management and opioid addiction, there’s a case to be made that states in the Midwest with growing elderly populations may, in fact, be aging into a drug crisis. Accompanied by rising labor force participation by older residents, the population may simply have more pains and greater access to money to pay for drugs.
Indiana’s Lawsuit Against Purdue Pharma
In a lawsuit filed by state Attorney General Curtis Hill in his official capacity, it is alleged that Purdue Pharma, L.P.; Purdue Pharma, Inc.; and The Purdue Frederick Company were critical players in bringing the opioid crisis to Indiana and that their actions in the process were deliberate. The attorney general’s office alleges that the Purdue enterprises violated a slew of state laws, including:
- The Deceptive Consumer Sales Act
- The Prescription Drug Discount and Benefit Cards Statute
- The False Claims Act
- The Medicaid False Claims Act
Among the allegations, the state claims that officers of the company and its representatives regularly tried to either minimize or deny the addiction risks associated with the opioids it sells. The lawsuit also states that Purdue Pharma exaggerated claims regarding how well its opioids could even treat chronic pain in the first place. More troubling, the attorney general’s office says that Purdue Pharma made a point of targeting its marketing toward older people and individuals who were “naive” about the topic of opioids with the intent of growing a long-term customer base.
According to the lawsuit, to further their ends, Purdue Pharma engaged in a campaign of misrepresenting its products to both consumers and medical practitioners throughout the state. Along these lines, the company is alleged to have paid individuals to represent themselves as neutral and independent providers of information. Worse, the state claims that many of the cases where prescriptions were filed were either entirely medically unnecessary or instances where a strong painkiller would not be considered appropriate.
Attorney General Hill stated that the lawsuit is the work product of more than two years of efforts by members of his office and other entities throughout the state of Indiana. As a proposed remedy for what has happened in the state, Indiana’s attorney general asks that the court:
- Impose the maximum penalties allowed by law
- Award damages to cover payments made by various state-funded or state-backed health plans and Indiana’s workers’ compensation system
- Award treble damages to the state
- Enter an order directing Purdue Pharma to cease all unlawful conduct
- Award court costs to the state
No exact financial figure is given. The entire lawsuit numbers a total of 98 pages, and it claims that the state has spent more than $200 million providing health programs related to prescription opioid problems and to develop research on the topic. The lawsuit was filed in Marion County, home of Indianapolis, the state capital. The state’s attorney general has indicated that he arrived at these conclusions after:
- Looking into financial statements from Purdue Pharma
- Conducting interviews with practitioners who have prescribed opioid-based products made by the company
- Doing depositions with former employees of the company
Purdue Pharma, for its part, has said the claims have no basis in fact and describes the charges as “inappropriate.” The company believes it has properly communicated all relevant data to all parties, and it makes a point to note that its products remain approved by the U.S. Food and Drug Administration as remedies that doctors should consider when dealing with patients who have serious pain management needs. Notably, the company did begin contributing money, about $20,000 per year, to expand programs in 10 Indiana counties that would allow officials to use computers to keep better track of individuals with substance use disorders.
At the peak of the prescription side of the state’s opioid epidemic in 2012, it is estimated that there were 112 prescriptions issued for every 100 residents of Indiana. By 2016, that figure had dropped to 84 prescriptions per 100 residents, a number that is still troubling.
It remains to be seen when the opioid crisis in the state will finally crest. In light of Indiana’s central location nationally, crisscrossed by several interstates that are considered drug highways, there are worries that the proven market of users in the state could mean the crisis will linger on for decades. Indiana continues to conduct research into the situation, reform laws to encourage treatment and explore options for holding allegedly responsible parties like Purdue Pharma accountable.