By Michael Booth
As a commissioner of Otero County in southeastern Colorado, Keith Goodwin thinks often about both the human costs of societal change and how those changes will impact the county’s budget.
So Goodwin remembers quite well one of the times the opioid epidemic in southern Colorado really hit home.
He was listening to the county coroner talk about budget changes, and the subject of body bags came up. The coroner needed to buy more than he’d budgeted for, because drug overdoses were drawing down the supply more quickly than expected.
“You hate to be measuring things by way of the coroner, because you know it's too late then,” Goodwin said.
Just to the southwest, in the even smaller county of Huerfano, County Administrator John Galusha has his own measuring sticks for how the explosion of opioid prescriptions in the past decade has affected Walsenburg and the surrounding ranch land.
“I see the jail rosters every day,” Galusha said, “and it’s ‘controlled substances,’ ‘controlled substances,’ ‘controlled substances.’”
Ask nearly any city or county leader in rural Colorado how they notice the opioid epidemic taking a human and fiscal toll, and the answers tumble out quickly. Ambulance districts that can’t stock enough Narcan to reverse opiate overdoses. Child welfare agencies that can’t find enough foster families to care for children taken away from addicted parents. Jails with soaring health care costs for addiction. Coroners paying for autopsy and funeral costs for addicted residents dying destitute.
“We don’t have that kind of money,” said Huerfano County Coroner Vonnie Valdez.
That blunt assessment is the fuel for a new series of anti-opioid lawsuits joined by cities and counties across Colorado, including the heavily affected southern swath of counties comprising Alamosa, Chaffee, Conejos, Huerfano, Las Animas and Otero. Joining a national wave of suits quickly being consolidated in an Ohio federal court, the Colorado jurisdictions seek compensation for opioid addiction costs from major manufacturers and distributors such as Purdue Pharma and Teva Pharmaceuticals.
The raw numbers in Colorado’s rural counties may appear small—dozens of overdoses and deaths, hundreds of emergency department visits—but the proportional cost in human and fiscal terms is enormous compared to urban areas.
The lawsuits, modeled after the Tobacco Master Settlement—where cigarette makers are paying billions of dollars to state governments—allege the opioid makers engaged in fraud and negligence in drug marketing, while enriching themselves at the expense of local service budgets.
Among other allegations, the lawsuits claim Purdue, Teva and others mislead physicians and patients about the dangers of addiction to opioids; made false claims about how long opioids would be effective before another dose was needed; and funded leading physicians and patient advocacy groups who pushed for wider prescribing of opioids to fight common pain.
One of the national lead attorneys in the opioid cases was also an architect of the tobacco settlement. Advocates cite Mississippi Attorney General Mike Moore in his summation of the logic: The lawsuits are “premised on a simple notion: you caused the health crisis; you pay for it,” he said.
Samuel Mitchell, a Denver attorney among those leading the lawsuits, said he was struck by talking to Las Animas County law enforcement officials about the inequitable impact of opioid abuse on small, rural populations.
“They can’t afford to buy Narcan; they have to decide whether to buy ammunition, or evidence collection kits, or Narcan, or needle-stick-proof gloves,” Mitchell said.
Conejos County saw its overdose deaths double, he added, “not because of an increase in pain or doubling of population, but because the manufacturers knew once they got them hooked, they would be hooked for life.”
The manufacturing defendants in the lawsuits have offered statements but not interviews on the allegations. Their court filings asking to dismiss the suits say the plaintiffs never name any prescribers who were allegedly deceived by false marketing. They also say the social costs borne by the cities and counties are the result of criminal misuse or addiction within a chain of opioid users that has nothing to do with their making of a product approved by the Food and Drug Administration (FDA).
In a statement forwarded by executive director of communications Robert Josephson, Purdue Pharma said, “We are deeply troubled by the prescription and illicit opioid abuse crisis, and we are dedicated to being part of the solution. As a company grounded in science, we must balance patient access to FDA-approved medicines, with collaborative efforts to solve this public health challenge. Although our products account for less than 2% of the total opioid prescriptions, as a company, we’ve distributed the CDC Guideline for Prescribing Opioids for Chronic Pain, developed three of the first four FDA-approved opioid medications with abuse-deterrent properties and partner with law enforcement to ensure access to naloxone. We vigorously deny these allegations and look forward to the opportunity to present our defense.”
At the very least, the teaming of motivated lawyers with local leaders is creating a new repository of the human and fiscal costs of the opioid epidemic in Colorado.
The counties in the lawsuits start from far back in the pack when addressing health and social service needs. Nearly all the counties currently joining the suits are at the bottom of per-capita income in Colorado. Conejos County, for example, had per capita income of $17,541, compared to the statewide average of $30,151, according to census data.
There are few (if any) residential drug abuse treatment centers in many rural counties, and social service administrators say they could easily use most of their budgets on expensive addiction treatment or group home placements on the Front Range.
The lawsuit Alamosa County has joined says the county spent nearly $3 million from 2012-17 on opioid-related expenses, for everything from child welfare to therapy and adoption legal fees. Conejos County says in the lawsuit that its annual health insurance premiums increased $200,000 “as a result of the opioid crisis.”
Related costs add up quickly. Increases in injection drug use—as those addicted to opioid pills often end up switching to cheaper and more accessible street heroin—inevitably leads to increases in needle-transmitted cases of hepatitis C and HIV.
A statewide report on the impact of opioid abuse said “potentially related” new cases of hepatitis C increased 80 percent from 2011-15, to 729 cases a year. State Medicaid officials have already expressed concerns about the eventual overwhelming costs for treating hepatitis C alone, with highly effective new courses of drugs coming at the steep cost of tens of thousands of dollars per patient.
Families affected by the crisis can also find the cycle of dependency, crime and child welfare disputes devastating to their finances, in areas of the state where it is already a challenge to find livable income.
The five-county lawsuit cites a Princeton University economist’s analysis that “opioid prescribing alone accounts for 20% of the overall decline in the labor force participation among working-age men from 2014-16, and 25% of the smaller decline in labor force participation among women.”
The manufacturers are defending themselves by noting that the lawsuits never make a direct connection between drugs lawfully manufactured and prescribed, and the ways in which they have been abused. The lawsuits do take pains, however, to portray opioids in much the same way previous class actions painted tobacco: as inherently dangerous, with their manufacturers and marketers misleading users about the risks.
Meanwhile, the manufacturers continue to benefit from the enormous market they helped create. Purdue’s sales of OxyContin, a popular form of painkiller, have fluctuated between $2 billion and $3 billion a year since 2009, the lawsuit said.
Valdez, the Huerfano County coroner, said overdose deaths in her county appear to have leveled off in recent years, in part because of tightened restrictions and recommendations on opioid prescribing. In 2015, her first year as coroner, there were four overdose deaths in the county of 6,500 people, from all sources. In 2016, there were six, with the most common overdoses being prescription opioids, heroin and methamphetamine. In 2017, it dropped to three again.
In addition to the tremendous human toll, the expenses from each case remain a problem for their small-budget county, she noted. Administrators have bumped up the coroner’s budget for indigent burials in recent years to $1,000 in 2017, from zero in 2015.
But each overdose autopsy costs $1,400, Valdez said. At times, when someone dies from an overdose, they have had addiction problems for so long that their families have cut off all ties. The county takes hours of personnel time to reach next of kin, and, often not finding any willing to participate in a funeral, has to take over burial costs of hundreds or thousands more.
With the crackdown on prescribed opioids, Valdez said, she fears overdoses will now balloon from easier-to-find street sources such as heroin and meth.
Local officials in Colorado say they are heartened by news of the Ohio judge pushing to consolidate all the national cases and get the parties into master settlement talks. They say that if they do see any compensation from the cases, they would first use the money to establish mental health and addiction treatment services in areas of Colorado long underserved in those fields, as well as youth education.
“I don’t think there’s anyone expecting the lawsuit will result in big dollars, but to the extent the county can avail itself of getting treatment and funding for that, that’s one of the driving motivations,” said Priscilla “Peter” Fraser, who until June was administrator for Las Animas County.
Southern Colorado officials are realistic, however, about the difficulty and time involved with the lawsuits compared to any local money received from potential opioid-related settlements. They are also mindful that even the tobacco settlement funds have been a political push-and-pull ever since the agreements were signed, with periodic budget shortages tempting Colorado and other states to divert tobacco-award money to other needs.
In Las Animas County, Fraser said, the mood is ripe for cooperation with surrounding counties hit hard by opioids to create regional treatment options, whether by telehealth or physical locations more convenient for patients than drives to Pueblo, Colorado Springs and Denver.
Evidence discovery in the lawsuit can also help smaller counties gather persuasive information as they apply for federal grants announced this spring through the U.S. Department of Agriculture (USDA). The Trump Administration said it was using the USDA as one place to set aside funds for local applicants to create things like mobile treatment centers.
Galusha in Huerfano County said he would like a little money to add mental health capacity to Huerfano’s tiny health department, which he described as the equivalent of a single-wide trailer for three employees, and no meeting space.
“We need to put a building in that people aren’t afraid to walk into, and give them some space to work,” Galusha said.