At the bankruptcy trial for Purdue Pharma LP, former company president Richard Sackler recently delivered remarkable testimony. Asked how many people in the US had died from misuse of OxyContin, Sackler said: “I don’t know.”

Over 700,000 deaths have been attributed to opioid overdoses since 1999. This grim toll exceeds the number killed by Covid-19. It is greater than the population of Boston, and almost double the number of US troops killed in WWII.

Covid made the opioid epidemic worse. Drug overdose deaths jumped 30% in 2020, to a record 92,000. Three-quarters of that tally came from opioids.

Overdose deaths are the visible tip of an opioid iceberg. Most addicts live through a dystopian progression that includes job loss, homelessness, and crime.

Richard Sackler’s claim that he is ignorant of this human tragedy is stunningly disingenuous. The Sackler clan owns Purdue Pharma LP, the maker of OxyContin. His father Raymond co-founded the company. Richard was a board member for almost three decades.

What caused the opioid epidemic? The answers are complex, but the gateway to addiction often begins with a legal prescription.

Even when applied for a limited period, opioids are addictive. In post-surgical pain management, an estimated 4.3% of people continue using opioids beyond their treatment protocol.

The genesis of the opioid crisis is rooted in an effort to expand the application of opiates beyond short-term use cases to address chronic pain.

As obesity, diabetes, and sedentary living took an increasing toll on the nation’s health, studies in the 1990s indicated roughly one-third of Americans were affected by chronic pain. This led directly to a push by drug companies and the federal government to expand the use of opioids in long-term scenarios.

Ironically, while opioids are demonstrably effective for treating acute pain, their effectiveness in treating chronic pain has always been vigorously debated. Because most individuals build up a tolerance over time, the addiction risks inherent to long-term usage often outweigh the benefits.

Despite those risks, in the 1990s and 2000s the pharma industry and the FDA steadily expanded the number of approved “indications” for which opioids could be used. Chronic scenarios, like persistent back pain, topped the list of new indications.

The opioid epidemic has been described as uniquely American. US prescription rates for opioids are 40% higher than countries like Germany or Canada.

The structure of the US healthcare system favors drugs over more expensive or holistic therapies, particularly in treating lower-income people. The prevalence of profit-oriented private health insurance arguably may contribute to this bias.

Regardless of the precise causes, our system is hooked on pharmaceuticals. In 1991 roughly 76 million painkiller prescriptions were issued in the US. By 2016 that number had increased to 289 million, roughly one prescription for every adult.

Economic stagnation also appears to be a factor fueling the opioid epidemic. A study recently published in JAMA compared counties where automotive plants had been shuttered with counties where similar plants remained open. Five years later, opioid overdose deaths were 85% higher in the counties that lost those jobs.

Another 2017 paper found that with each percentage point increase in the unemployment rate, the death rate from opioids rises by 3.6%. This economic distress correlation may help explain why opioid abuse is more prevalent in rural and rust belt communities.

The most commonly prescribed opioids are oxycodone (trade names OxyContin, Percocet) and hydrocodone (Vicodin, Norco). As the volume of prescriptions soared, drug companies also brought more potent (and addictive) versions to market. By 2012, more than a third of pain prescriptions were more powerful than morphine.

These facts feature prominently in thousands of civil lawsuits brought by states, cities, and others alleging that opioid producers like Purdue Pharma are liable for their role in fomenting the opioid crisis. It is those lawsuits that pushed Purdue to declare bankruptcy.

Purdue is now seeking bankruptcy court approval of a settlement that would dedicate all the company’s assets to fighting the opioid crisis and see Sackler family members contribute $4.3 billion over 10 years to those efforts. In exchange, the Sacklers would receive legal protection from further lawsuits.

As part of the settlement Purdue will also plead guilty to criminal charges related to the marketing of OxyContin. In 2007 the company previously plead guilty to “misbranding” OxyContin and acknowledged it had trained sales representatives to mislead physicians about addiction risks.

Richard Sackler also testified he “didn’t recall” details about marketing programs Purdue utilized, including an initiative called “Evolve to Excellence” (E2E) that authorities have alleged led healthcare providers to write medically-unnecessary prescriptions of OxyContin.

Consulting giant McKinsey & Co. pitched the E2E program to Purdue as a method to increase OxyContin sales. McKinsey agreed to a $573 million settlement with states earlier this year for its role in the opioid crisis – without admitting wrongdoing of course.