OSWEGO COUNTY – As reported last week, the county, having suffered through years of what has undeniably been an opioid crisis, may soon see its first installment of a court-ordered settlement with manufacturers and distributors of opioids, plus chain pharmacies, worth between $2.3 million and almost $4.1 million spread over 18 years, all of which must be used for opioid remediation.
A resolution to accept the settlement and drop all further claims was unanimously passed by the County Legislature at its Sept. 9 meeting. Acceptance of the settlement was recommended by County Attorney Richard Mitchell and the Legislature’s Government, Courts, and Consumer Affairs Committee.
This settlement is specifically referred to as the Distributors New York Settlement Agreement and specifically targets McKesson Corp., Cardinal Health, Inc., and AmerisourceBergen Corp. and its terms are intended to parallel the wider Distributor Global Settlement Agreement currently under negotiation. According to the 215-page New York Settlement Agreement, New York intends to join the Global Settlement, which should it become effective by July 1, 2022, will supersede the terms of the New York Settlement Agreement for the most part. Its global payout could amount to $18.6 billion. New York state would receive 5.39% of that amount, equaling approximately $1 billion, plus an additional $27.5 million in restitution.
The total payout to New York state under the New York Settlement Agreement would be close to that under the Global Settlement. There may be differences in the payment of attorneys’ fees, worth many millions, and other factors.
The distributors will be under strict guidelines regarding their ability to make the annual installment payments required. No deferment of payments will be allowed in the first three years of payments. After that, strict rules apply and certain proof of a distributor’s inability to pay must be provided. The distributor’s buyback of its stock shares or the acquisition of other assets will not be allowed as an excuse for an inability to pay, nor will it be allowed during the period of a payment deferral. If a distributor is able to only pay part of its annual installment, it must pay that and defer the rest. Anything deferred must be repaid in the next year with interest.
However, bankruptcy of any or all of the distributors is a possibility, leaving the county to “seek to continue the payments, but under the auspices of the bankruptcy court,” according to Jayne Conroy of Simmons Hanly Conroy, LLC, attorneys for the county in this settlement case.
Regarding the lengthy 18-year payment schedule, Conroy said, “the length of time is intended to maximize the payout by allowing the settling corporations to stay in business and contribute yearly. It also maximizes flexibility and longevity with abatement and rehabilitation efforts. The consequences of the opioid epidemic will take a long time to abate, and payment over time assures funded programs for a long period.”
The effects of opioids on this country and this county would be hard to overestimate. Overdose deaths involving opioids, including prescription opioids, heroin, and synthetic opioids (like fentanyl), have increased over six times since 1999. According to the CDC (Centers for Disease Control and Prevention), “Nearly 841,000 people have died since 1999 from a drug overdose. In 2019, 70,630 drug overdose deaths occurred in the United States. Opioids—mainly synthetic opioids (other than methadone)—are currently the main driver of drug overdose deaths, making it a leading cause of injury-related death in the United States. 72.9% of opioid-involved overdose deaths involve synthetic opioids. Opioids were involved in 49,860 overdose deaths in 2019 (70.6% of all drug overdose deaths).
Drug overdose deaths continue to increase in the United States.
According to the CDC, from 1999–2019, nearly 500,000 people died from an overdose involving any opioid, including prescription and illicit opioids.
This rise in opioid overdose deaths can be outlined in three distinct waves.
The first wave began with increased prescribing of opioids in the 1990s, with overdose deaths involving prescription opioids (natural and semi-synthetic opioids and methadone) increasing since at least 1999.
The second wave began in 2010, with rapid increases in overdose deaths involving heroin.
The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids, particularly those involving illicitly manufactured fentanyl. The market for illicitly manufactured fentanyl continues to change, and it can be found in combination with heroin, counterfeit pills, and cocaine.
Opioids are substances that work in the nervous system of the body or in specific receptors in the brain to reduce the intensity of pain.
Prescription opioids can be prescribed by doctors to treat moderate to severe pain but can also have serious risks and side effects.
Prescription opioids can be used to treat moderate-to-severe pain and are often prescribed following surgery or injury, or for health conditions such as cancer. In recent years, there has been a dramatic increase in the acceptance and use of prescription opioids for the treatment of chronic, non-cancer pain, such as back pain or osteoarthritis, despite serious risks and the lack of evidence about their long-term effectiveness.
Since the 1990s, when the amount of opioids prescribed to patients began to grow, the number of overdoses and deaths from prescription opioids has also increased. Even as the amount of opioids prescribed and sold for pain has increased, the amount of pain that Americans report has not similarly changed.
From 1999 to 2019, nearly 247,000 people died in the United States from overdoses involving prescription opioids. Overdose deaths involving prescription opioids more than quadrupled from 1999 to 2019.
More than 191 million opioid prescriptions were dispensed to American patients in 2017—with wide variation across states.
There is a wide variation of opioid prescription rates across states. Health care providers in the highest prescribing state, Alabama, wrote almost three times as many of these prescriptions per person as those in the lowest prescribing state, Hawaii.
Studies suggest that regional variation in use of prescription opioids cannot be explained by the underlying health status of the population.
The most common drugs involved in prescription opioid overdose deaths include: Methadone, Oxycodone (such as OxyContin®), and Hydrocodone (such as Vicodin®).
According to the CDC, anyone who takes prescription opioids can become addicted to them. In fact, as many as one in four patients receiving long-term opioid therapy in a primary care setting struggles with opioid addiction. Once addicted, it can be hard to stop. In 2016, more than 11.5 million Americans reported misusing prescription opioids in the past year.
Taking too many prescription opioids can stop a person’s breathing—leading to death.
Prescription opioid overdose deaths also often involve benzodiazepines. Benzodiazepines are central nervous system depressants used to sedate, induce sleep, prevent seizures, and relieve anxiety. Examples include alprazolam (Xanax®), diazepam (Valium®), and lorazepam (Ativan®). The CDC recommends avoiding taking benzodiazepines while taking prescription opioids whenever possible.
Fentanyl is a synthetic opioid pain reliever. It is many times more powerful than other opioids and is approved for treating severe pain, typically advanced cancer pain. Illegally made and distributed fentanyl has been on the rise in several states.
Pharmaceutical fentanyl is a synthetic opioid, approved for treating severe pain, typically advanced cancer pain. It is 50 to 100 times more potent than morphine. It is prescribed in the form of transdermal patches or lozenges and can be diverted for misuse and abuse in the United States.
However, most recent cases of fentanyl-related harm, overdose, and death in the U.S. are linked to illegally made fentanyl. It is sold through illegal drug markets for its heroin-like effect. It is often mixed with heroin and/or cocaine as a combination product—with or without the user’s knowledge—to increase its euphoric effects.
In 2019, more than 36,000 deaths involving synthetic opioids (other than methadone) occurred in the United States, which is more deaths than from any other type of opioid. Synthetic opioid-involved death rates increased by over 15% from 2018 to 2019 and accounted for nearly 73% of all opioid-involved deaths in 2019. The rate of overdose deaths involving synthetic opioids were more than 11 times higher in 2019 than in 2013.
The latest provisional drug overdose death counts through May 2020 suggest an acceleration of overdose deaths during the COVID-19 pandemic.
Previous reports have indicated that increases in synthetic opioid-involved deaths have been associated with the number of drug submissions obtained by law enforcement that test positive for fentanyl but not with fentanyl prescribing rates. These reports indicate that increases in synthetic opioid-involved deaths are being driven by increases in fentanyl-involved overdose deaths, and the source of the fentanyl is more likely to be illicitly manufactured than pharmaceutical.
There are also fentanyl analogs, such as acetylfentanyl, furanylfentanyl, and carfentanil, which are similar in chemical structure to fentanyl but not routinely detected because specialized toxicology testing is required. Recent surveillance has also identified other emerging synthetic opioids, like U-47700. Estimates of the potency of fentanyl analogs vary from less potent than fentanyl to much more potent than fentanyl, but there is some uncertainty because potency of illicitly manufactured fentanyl analogs has not been evaluated in humans. Carfentanil, the most potent fentanyl analog detected in the U.S., is estimated to be 10,000 times more potent than morphine.
In New York state, the change in drug overdose death rates involving synthetic opioids from 2018 to 2019 increased 7.1%, according to the CDC. These overdoses resulted in 2,195 deaths statewide in 2018 and 2,338 deaths in 2019.
On the other hand, drug overdose death rates involving prescription opioids from 2018 to 2019 in New York state fell 4.1% from 998 deaths in 2018 to 939 deaths in 2019.
The overall opioid prescribing rate in the United States peaked and leveled off from 2010-2012 and has been declining since 2012, but the amount of opioids in morphine milligram equivalents (MME) prescribed per person is still around three times higher than it was in 1999. MME is a way to calculate the total amount of opioids, accounting for differences in opioid drug type and strength.
There was a more than 19% reduction in annual prescribing rate from 2006 to 2017. The declines in opioid prescribing rates since 2012 and high-dose prescribing rates (≥90 MME) since 2008 suggest that healthcare providers have become more cautious in their opioid prescribing practices.
In 2017, however, there were still almost 58 opioid prescriptions written for every 100 Americans.
More than 17% of Americans had at least one opioid prescription filled, with an average of 3.4 opioid prescriptions dispensed per patient.
Per prescription, the average daily amount was more than 45.3 MME.
The average number of days per prescription continues to increase, with an average of 18 days in 2017.
There is wide variability at the county level in the amount of opioids received per resident. Counties with higher prescribing have been shown to have these characteristics: generally smaller cities or larger towns; higher percentage of white residents; higher number of dentists and primary care physicians per capita; more people who are uninsured or unemployed; and more residents who have diabetes, arthritis, or a disability.
Heroin is an illegal opioid. Nearly 40 people die every day from an overdose death involving heroin in the United States. However, heroin overdose deaths in New York state decreased between 2018 and 2019 by 9.5% from 1,243 deaths in 2018 to 1,145 in 2019.
Over 28% of all opioid overdose deaths in 2019 involved heroin. Not only are people using heroin, they are also using multiple other substances, including cocaine and prescription opioids. Nearly all people who use heroin also use at least one other drug.
However, from 2018 to 2019, the heroin-involved overdose death rate decreased by over 6% throughout the United States as a whole. Factors that may contribute to the decrease in heroin-involved deaths include fewer people initiating heroin use, shifts from a heroin-based market to a fentanyl-based market, increased treatment provision for people using heroin, and expansion of naloxone access.
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