SALT LAKE CITY — Opioids killed at least 460,000 Americans — roughly equivalent to the population of Miami — in an epidemic that spans 20 years. That’s a death toll not far shy of the number of Americans who died in World War II and the Vietnam War combined.

Now the manufacturers of prescription opioids are in the middle of a reckoning that promises to cost at least billions of dollars before it’s all settled.

But even despite all the warnings, the trend of opioid abuse is not going down, according to Meghan Balough, a violence and injury prevention epidemiologist in the Utah Department of Health. While the number of opioid overdose deaths in Utah decreased from 449 to 369 between 2016 and 2017, they climbed to 417 in 2018.

“Even a few years ago, we were fourth in the nation for prescription opioid deaths. Then we moved to No. 7. Now we’re 21,” she said.

However, Utah’s “improved” ranking largely reflects the problem in other states got worse, not that Utah greatly improved, she said.

Most of the deaths over the past 20 years are attributed to drugs legally prescribed for pain management that proved to be addictive. As the death toll has risen in virtually every state, even people not affected have heard warnings about appropriate pain management with oxycodone, hydrocodone, methadone and other opioids. The numbers also include deaths from illicit opioids, especially heroin.

Opioid addiction is not a young people problem, as occurs when youths experiment with drugs. Those most likely to become addicted to opioids and possibly die in Utah are middle-aged folks who were injured and prescribed painkillers, Balough said.

Eight Utahns die each week from an opioid overdose, five of them related to prescription opioids. Nationwide, the Centers for Disease Control and Prevention noted 132 deaths a day from opioids in 2017, but didn’t distinguish between prescribed and illicit drugs.

The Deseret News took a deep dive into opioids’ impact on Utah in 2017-2018. The award-winning series, “The Hidden Plague,” told the story of two boys who died after obtaining synthetic “pink” from China and took a close look at Utah drug kingpin Aaron Shamo, now awaiting sentencing for running a nationwide opioid trafficking ring. The series also profiled many Utahns from all walks of life who battled opioid addiction, from a school superintendent and LDS bishop to a former BYU football player whose injuries led to addiction and others across a span of careers and life stories.

That’s the thing with opioid addiction, experts told the Deseret News. Opioid addiction can claim anyone.

Settlements raise questions

Most of the courtroom action around opioid deaths has actually taken place in conference rooms as drugmakers and distributors hammer out deals to avoid trials and the potential for large damage awards.

3 waves of U.S. opioid overdose deaths | CDC

The New York Times reported this week that opioid manufacturer Teva Pharmaceutical Industries, located in Israel, and three large U.S. distribution companies have agreed to cash payouts and in-kind donations totaling $260 million to avoid what was to be the first of a series of federal trials related to opioid deaths across America. Two Ohio counties filed the suit.

Between them, McKesson, AmerisourceBergen and Cardinal Health distribute the vast majority of medicines to the U.S. pharmacies, clinics and hospitals from which consumers will access them.

The settlements with Ohio’s Summit and Cuyahoga counties are the leading edge of a huge legal wave. NPR reported that, “As the first to go to trial, their lawsuits had been expected to serve as a bellwether for the nearly 3,000 lawsuits that have been folded into one massive federal case known as the National Prescription Opiate Litigation.”

“Those thousands of lawsuits — filed by city, county and tribal representatives against companies in virtually every link of opioid drug production — remain on track for eventual trials if they do not reach settlements of their own,” according to NPR.

Some companies have already floated settlements to avoid the trial, including Johnson & Johnson, Mallinckrodt Pharmaceuticals, and Purdue Pharma, “which has been largely blamed for igniting the opioids crisis with misleading marketing of its drug OxyContin,” the Times said. It noted that Purdue reached a tentative agreement in September involving cash from its owners, members of the Sackler family, who also agreed to restructure the drug maker into a public company whose profits would go to the cities, counties and states for costs related to the epidemic, the total value expected to be in the billions. The agreement, though, is mired in Purdue’s bankruptcy proceedings.

Besides individual cities and towns, attorneys general in multiple states have filed or joined lawsuits that are pending. So are close to 2,300 cases by local governments like the two in Ohio. The Times noted Monday that “even as the two-county settlement was being announced, the drug distributors and other corporate defendants in the trial were pursuing a global deal, worth $48 billion in cash and donated addiction treatments, to resolve all opioid lawsuits against them.”

State tragedies

While settlements and rumors of cash awards circulate, the sheer volume of lawsuits and proposals and different governments involved — including states and cities and Native American tribes — means any final award tally is very much up in the air.

Lawsuits may be negotiated separately, then there’s a process for determining who gets what and that’s bound to be complicated, with formulas that consider many different factors. Those factors include how big a state’s population is and how severe the problem has been in each one, income levels and more, said Richard Piatt, spokesman for Utah’s Attorney General’s Office. It amounts to a lot of moving pieces — and the process can move quite slowly.

Nor is all the help coming from lawsuits. The Trump administration announced in September $1.8 billion in grants to help states and local governments combat the opioid epidemic, according to the U.S. Department of Health and Human Services. Utah’s share is $24 million.

Utah to receive $24 million in federal funding to combat state’s opioid crisis

States have taken different approaches to reducing the harm of opioids. Most of Utah’s deaths are from prescription drugs, not heroin, which is a bigger issue elsewhere. The involvement of legal prescription drugs has been especially challenging. “How do you tell someone who has been injured and goes to the doctor and gets an operation that there’s a risk to handling their pain?” Balough asked.

Much of the Utah Health Department’s work is with prescribers, looking at how to avoid over-prescribing and also alternatives, even alternating ibuprofen and Tylenol. They talk to pharmacists about being proactive in warning those who fill prescriptions. Utah also has a more generic education campaign that includes billboards reminding drivers that tramadol or oxycodone are opioids.

Meanwhile, the Bureau of Epidemiology focuses on disease prevention and worries about people who were prescribed opioids, became addicted, then moved to heroin because of the cost or because their doctor wouldn’t prescribe more and are at risk of contracting diseases like hepatitis C and HIV.

When the dust settles, healthcare providers, addiction experts and others may find themselves at odds with governments over where settlement dollars should go. USA Today published an expert wish list that included harm-reduction efforts, drug-abuse prevention program, programs to help addicts quit and long-term services to support recovery.

“Will states repeat the mistakes of the tobacco settlement?” the article asked, pointing out that much of the money tobacco companies paid went into states’ general funds, rather than to tobacco-use prevention or mitigation.

Correction: An earlier version incorrectly stated the value of the proposed settlement with Purdue Pharma and the Sackler family was $145 billion. No exact figure has been determined but is expected to be dramatically less, but expected to exceed $10 billion.