After the Opioid Settlement, Nothing Changed
Pharmaceutical companies paid $26 billion for their role in the opioid epidemic. Overdose deaths hit a new record the following year. What the settlements tell us about accountability in America.
In 2021, four major pharmaceutical distributors — McKesson, Cardinal Health, AmerisourceBergen, and Johnson & Johnson — agreed to pay $26 billion to settle opioid-related claims brought by state and local governments. It was the largest public health settlement in American history, exceeded only by the 1998 tobacco settlement. It resolved thousands of lawsuits, distributed funds to state and local governments for addiction treatment programs, and allowed the companies involved to avoid criminal liability and continue operating.
In 2022, overdose deaths in the United States reached 109,680 — the highest number on record. In 2023, the number was 107,543. In 2024, with fentanyl and other synthetic opioids accounting for more than 90 percent of overdose deaths, the number was 104,212 — declining slightly but still at levels that, in any year before 2017, would have been described as a public health catastrophe.
The opioid settlement resolved the legal claims. It did not address the opioid crisis. These are related but different things, and the distance between them reveals something important about how the American legal and regulatory system handles corporate accountability for mass harm.
What the settlement actually did
The $26 billion Sackler/Purdue settlement, the $26 billion distributor settlement, and the dozens of smaller settlements with pharmacy chains, consultants, and other parties have created a significant stream of public funding for addiction treatment, harm reduction, and recovery services. This is real and valuable; the funding has enabled expanded naloxone distribution, medication-assisted treatment programs, and recovery housing initiatives that were previously underfunded.
What the settlements did not do: require any significant behavioral change by the settling companies; result in criminal convictions for executives responsible for the conduct at issue; produce structural reform of the pharmaceutical supply chain that allowed opioid overprescribing to occur; or address the underlying conditions — chronic pain, despair, social isolation, economic dislocation — that made populations vulnerable to opioid addiction.
The criminal accountability gap is particularly striking. The primary conduct at issue — the deliberate misleading of prescribers about the addiction risk of opioids, the targeted marketing of high-dose formulations to the highest prescribers, the failure of distributors to flag and report suspicious orders — was conduct that, had it been committed by individuals without corporate intermediation, would likely have resulted in criminal charges. It was committed by corporate actors with extensive legal and government affairs infrastructure, and the result was civil settlements that no individual will go to prison for.
The Sackler family, whose members directed Purdue Pharma's opioid marketing strategy, received a controversial immunity provision in the original Purdue bankruptcy settlement; the Supreme Court's 2024 ruling in Harrington v. Purdue Pharma held that the bankruptcy code does not permit non-debtor third-party releases, sending the case back for renegotiation. The renegotiated settlement, reached in late 2024, required the Sacklers to pay approximately $7 billion while maintaining their status as non-debtors. No Sackler family member has been criminally charged.
The crisis after the settlement
The shift from prescription opioids to illicit fentanyl — which was well underway before the settlements — means that the regulatory and legal interventions aimed at pharmaceutical companies are addressing the origin of the crisis rather than its current form. The overdose deaths of 2024 are not from OxyContin; they are from illicit fentanyl, largely synthesized in Mexico from Chinese precursor chemicals and distributed through supply chains that are disconnected from the pharmaceutical system entirely.
This shift has several implications. First, the harm reduction interventions that are most effective for the current crisis — naloxone distribution, supervised consumption sites, drug checking services, fentanyl test strip availability — are primarily public health tools rather than legal or regulatory ones, and their political viability varies dramatically by jurisdiction. Second, the populations most affected by the current fentanyl epidemic are different from those most affected by the prescription opioid epidemic; the demographics of overdose have shifted toward younger Black and Hispanic urban residents, and the political attention to their deaths has been less sustained than the political attention to the white rural deaths that drove the initial legislative and litigation response.
Metaculus forecasts a 28 percent probability that annual US overdose deaths will decline below 80,000 — a reduction of approximately 25 percent from current levels — before 2030. The probability reflects both the genuine progress being made by harm reduction interventions and the structural challenges of a crisis driven by a highly potent, cheap, and difficult-to-detect substance flowing through complex supply chains.
Devon Mitchell is a contributing editor at The Auguro covering ideas, democracy, and the politics of knowledge.