Corporate Accountability and Public Health: Sackler Ruling and Treatment Gaps in the Opioid Crisis

The US Supreme Court’s recent decision to strip the Sackler family of immunity from opioid-related lawsuits marks a pivotal moment in the fight for corporate accountability in public health crises. As the legal battle intensifies, a new report reveals a troubling gap in access to lifesaving opioid treatment for vulnerable populations, highlighting the dual challenge of seeking justice for the past while addressing urgent public health needs today.

The pivotal 2024 Supreme Court decision overturned a bankruptcy court decision that granted the Sackler family—owners of Purdue Pharma—immunity from lawsuits related to the opioid crisis. The ruling, stemming from the Harrington v Purdue Pharma case, could signal a shift in this dynamic, according to an article published in JAMA.¹

The US Supreme Court’s recent decision to strip the Sackler family of immunity from opioid-related lawsuits marks a pivotal moment in the fight for corporate accountability in public health crises.

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Meanwhile, a new report from the Office of Inspector General (OIG) highlights the significant barriers for Medicare and Medicaid enrollees in accessing medications for opioid use disorder (MOUD).² While many populations aside from Medicare and Medicaid enrollees continue to be impacted by this crisis, the Supreme Court’s actions, paired with the newest data demonstrating the public impact, illustrate the legal potential in addressing the opioid crisis and the ongoing public health challenges of treatment access.

“As the United States continues to struggle with the opioid crisis, access to medications that treat opioid use disorder (MOUD) is essential to address the high rates of opioid use disorder and overdose mortality,” Louis A. Day, team leader and social science research analyst for the Office of Evaluation and Inspections, said in a statement.³ “Medicare and Medicaid play important roles in providing MOUD, but access concerns persist in both programs. For example, HHS-OIG has found that hundreds of counties in high need of MOUD services had few or no MOUD providers treating Medicare or Medicaid enrollees, and many enrollees with opioid use disorder did not receive MOUD through their respective programs.”

Purdue Pharma and the Sackler Family’s Role in the Opioid Crisis

In 1996, Purdue Pharma launched a strategy to promote OxyContin, an extended-release version of oxycodone.¹ By aggressively marketing the drug and downplaying its addiction risks, Purdue fostered an environment that encouraged the overprescription of opioids, the JAMA authors wrote. The company more than doubled its sales force and funded over 20,000 educational programs aimed at physicians while misrepresenting the risk of addiction as less than 1%. OxyContin sales surged 2300% between 1996 and 2000, by which time the drug had become a leading substance of abuse in the US, fueling the opioid crisis and vaulting the Sackler family into the ranks of America's wealthiest.

According to the article, as the opioid crisis worsened, Purdue and the Sacklers faced thousands of lawsuits. To evade liability, the Sacklers used 2 major strategies: First, after settling criminal charges with the federal government in 2007, they siphoned billions of dollars from Purdue into offshore accounts. Then, in 2019, Purdue declared bankruptcy, but the Sacklers themselves retained much of the fortune extracted from the company.

Supreme Court Overturns Sacklers’ Immunity

In 2021, a bankruptcy court approved a settlement that granted the Sacklers immunity from further lawsuits in exchange for a $6 billion payout, some of which was designated for public health programs. However, critics argued that this deal allowed the Sacklers to escape full accountability while retaining billions of dollars, setting a dangerous precedent for corporate misconduct.

On June 27, 2024, the Supreme Court overturned this immunity in a 5-4 decision, sending the case back to the bankruptcy court for renegotiation. The ruling emphasized that bankruptcy protections are intended for honest debtors who fully disclose their assets—not for individuals who attempt to shield billions in offshore accounts while avoiding liability for their actions.

The Sacklers now face renewed litigation from individuals affected by opioid misuse, as well as state and local governments. They must either cut a consensual deal with plaintiffs or file for bankruptcy themselves. The authors emphasized that this decision significantly raises the stakes for the Sackler family and could set an important legal precedent for corporate accountability in public health crises.

Implications for Public Health and Corporate Accountability

The opioid crisis costs the US between $50 billion and $600 billion annually. While the original $6 billion settlement was intended to provide some financial relief, the article cited prominent arguments that stated the price is insufficient compared with the scale of devastation caused by the crisis.

“The case illuminates how those in power who cause public health harm have used legal tactics, including bankruptcy, to dodge accountability from the US legal system,” the article stated. “Even as Harrington cuts off 1 mechanism for avoiding accountability, many others need to be addressed to establish legal safeguards against corporate misconduct that contributes to the brunt of US morbidity and mortality.”

Are Regional Initiatives Enough to Combat the Opioid Crisis?

Despite the increasing prevalence of substance use disorders, particularly opioid use disorders, access to medication and treatment remains a steadfast barrier.³ Medical centers and health care networks are striving to mitigate these barriers in various pockets of the country, though many on the frontlines emphasize the urgent need for further progress.

In an interview with The American Journal of Managed Care^® (AJMC^®), Michael Lynch, MD, associate professor of emergency medicine at the University of Pittsburgh and attending emergency physician and medical toxicologist at the University of Pittsburgh Medical Center, explained how his center has had success with telemedicine.

“In general, we know about three-quarters of people who have a substance use disorder don't receive any treatment at all. Fewer than a fifth of people with opioid use disorder actually receive medication treatment, and a lot of the barriers are logistical,” he said. “People don't know where to go. They have to wait. There are a lot of hoops to jump through to be able to access that evidence-based care.”

While center-specific initiatives can alleviate harm reduction, there are societal and systemic barriers that play a large role in inhibiting access to care for the many Americans living with substance use disorders.

“There are a lot of stigma concerns, transportation, childcare, work, you name it—just lots of barriers, and those have always existed and continue to,” Lynch said. “What we found is that the telemedicine bridge clinic really helps to address those barriers, to at least help people get started and stabilized while we transition them to a longer term, maybe more traditional in-person or hybrid model.”

These barriers still exist among populations that see physicians regularly and are insured; unfortunately, when looking at marginalized communities like those with low or no income, without housing, or the recently incarcerated, the gap to accessing care widens, as does the possibility of encountering stigma from providers.

The Center for Inclusion Health’s Urban Health Outreach at Allegheny Health Network works to bridge gaps for these populations by bringing health care and education directly to the community.⁵ But according to Mary Sligh, CRNP, team lead of street medicine, Urban Health Outreach, the inaccessibility of treatment extends beyond community-based care programs like these that strive to bridge these gaps.

“We really make an effort to promote destigmatized health care, whether it's substance use disorders or just providing care for folks experiencing homelessness or have been historically marginalized from health care,” Sligh said in an interview with AJMC. “We really try to set an example for our peers, but also to directly teach them and train our peers because we shouldn't be the only people in the health system who can take care of somebody who's homeless—we have failed if we're the only people who can do this work.”

OIG Report Exposes Gaps in Access to Opioid Treatment

While the legal landscape surrounding the opioid crisis evolves and autonomous health initiatives aim to address it, the public health challenge persists, as does the urgency of ensuring access to treatment. The OIG report shed light on critical gaps in access to MOUD, particularly among Medicare and Medicaid enrollees.²

The findings reveal that 19% of counties lack any MOUD provider, while nearly one-third of counties have no providers who accept Medicare or Medicaid. This disparity is especially pronounced among office-based buprenorphine providers, many of whom do not serve these populations, even though most opioid treatment programs do. Additionally, administrative and financial challenges make it difficult for MOUD providers to operate in high-need areas, further exacerbating treatment shortages.

The OIG report provided several recommendations to improve access to MOUD services:

1. Geographically targeted efforts to increase the number of MOUD providers in high-need counties.
2. Assessment of reimbursement rates to ensure that Medicare and Medicaid payments for MOUD services are sufficient to attract and retain providers.
3. Establishment of a national directory of MOUD providers to help individuals locate providers willing to treat Medicare and Medicaid enrollees.

As the US continues to grapple with the opioid crisis, the Harrington v Purdue Pharma ruling marks a significant step toward holding corporate executives like the Sacklers accountable for their role in public health disasters. Simultaneously, addressing the gaps in access to MOUD, as highlighted in the OIG report, remains a critical public health priority.

References

1. Aaron DG, Levitin AJ, Sinha MS. Legal accountability for health crises: “unshielding” the Sackler family. JAMA. Published online September 25, 2024. doi:10.1001/jama.2024.16200

2. Medicare and Medicaid Enrollees in Many High-Need Areas May Lack Access to Medications for Opioid Use Disorder. Office of Inspector General; September 2024. Accessed October 1, 2024. https://oig.hhs.gov/documents/evaluation/9999/OEI-BL-23-00160.pdf

3. HHS OIG. HHS-OIG's efforts to address the opioid epidemic. September 27, 2024. Accessed October 1, 2024. https://oig.hhs.gov/newsroom/news-releases-articles/hhs-oigs-efforts-to-address-the-opioid-epidemic/

4. Shaw M. Combatting the opioid epidemic: insights from the front lines. AJMC. September 2, 2024. Accessed September 30, 2024. https://www.ajmc.com/view/combatting-the-opioid-epidemic-insights-from-the-front-lines

5. Grossi G. Frameworks for advancing health equity: Urban Health Outreach. AJMC. May 9, 2024. Accessed September 30, 2024. https://www.ajmc.com/view/frameworks-for-advancing-health-equity-urban-health-outreach