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    Anti-opioid groups are ‘optimistic’ about Trump’s tariffs. Will the move help tackle the fentanyl crisis?

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    Anti-opioid campaigners in the US have welcomed Donald Trump’s threat to hit Mexico, China and Canada with increased trade tariffs if they do not curb the smuggling of the powerful drug driving the US opioid epidemic.Families and doctors grappling with a crisis that has claimed about 900,000 lives say the move may signal that a second Trump administration will finally get serious about tackling the flow of fentanyl into the US. But they also warn that much more needs to be done to reduce demand for opioids and to rein in the power of the pharmaceutical industry which created the epidemic.Trump said last week that he will issue an executive order on his return to the US presidency next month imposing a 25% tariff on goods from Mexico and Canada until their governments clamp down on the smuggling of fentanyl and other drugs into the US, and on people crossing the northern and southern borders illegally.The president-elect also said he will impose a 10% additional tariff on imports from China as the leading manufacturer of the precursor chemicals used by drug cartels to manufacture fentanyl, a highly potent synthetic opioid that is now the single largest cause of drug overdose deaths in the US.Ed Bisch, who lost his 18-year-old son Eddie to a prescription opioid overdose in 2001, said that tariffs are a sign that Trump “means business”.“I’m optimistic that the threat of substantial tariffs will lead to major cooperation in reducing the fentanyl poisoning of America,” he said.Bisch and other campaigners also say that some of Trump’s cabinet choices may signal a greater engagement with the crisis by the next administration, particularly as Robert F Kennedy Jr, who is nominated as health secretary, was a heroin user and the vice-president-elect, JD Vance, wrote a bestselling book, Hillbilly Elegy, about growing up in a household and region hit by drug addiction.Trump campaigned in 2016 and again this year on commitments to tackle the opioid epidemic which has devastated regions of America in ways that are often unseen in other parts. The crisis dragged entire communities deeper into poverty, drove up crime and greater dependency on welfare, and tore families apart.Millions of children have been raised by their grandparents because the intervening generation was imprisoned, dead or in no condition to parent. In West Virginia, the state worst hit by the epidemic, nearly half of all grandparents are raising their grandchildren.The opioid crisis has also played an important part in undermining public confidence in government institutions and medical practice in parts of the US because the epidemic grew out of the pharmaceutical industry pushing the wide prescribing of narcotic pain killers from which drug makers made billions of dollars with the complicity of the Food and Drug Administration (FDA). The epidemic then evolved as illegal supplies of heroin and then fentanyl drove up the death toll.But critics say Trump failed to follow through on his campaign promises in 2016 and his next administration will be a test of how really committed is he is on the issue in the face of what is likely to be major pushback from the drug industry.As president in 2017, Trump declared the opioid crisis a public health emergency.“No part of our society, not young or old, rich or poor, urban or rural has been spared this plague,” he said at the time.But two years later, the Government Accountability Office (GAO) criticised the Trump administration for a lack of coordination of efforts and failing to fulfill a legal requirement to issue a national drug control strategy.Robert Kent, who served as general counsel for the White House office of national drug control policy under Joe Biden, credits Trump with declaring the epidemic an emergency and establishing an opioid commission that issued guidelines on how to combat the crisis.“In Trump’s first term, he was the one who declared an opioid public health emergency, which is still in effect. The problem was there were no concrete actions taken specifically as a result. He didn’t put significant new resources into it,” he said.Kent said that the Biden administration put a greater emphasis on “harm reduction” such as the provision of overdose antidotes and test strips allowing drug users to detect fentanyl. But he fears those may be in danger from Republicans who see such measures as enabling drug use.Andrew Kolodny, director of Physicians for Responsible Opioid Prescribing and one of the first doctors to raise the alarm about the dangers of mass prescribing prescription painkillers, said harm reduction was necessary but did not get to the root causes of the epidemic.“It’s not hard for Trump to do better than Biden did on opioids. There were some good things that came out of the Biden administration. It was nice to see the federal government move more in a direction of harm reduction. But beyond that there wasn’t really that much done so by Biden,” he said.“When Biden ran for office, he put out a platform on how he would address the opioid crisis if he was president, and it was an excellent platform. But he never really implemented the plan.”Kolodny said that if Trump wants to have a significant impact in reducing opioid addiction he needs to create cheaper and easier access to treatment.“The vast majority of people with opioid use disorder actually want help for it. The reason they keep using fentanyl is that it’s much easier to get fentanyl and cheaper to get fentanyl than it is to get yourself onto buprenorphine or methadone treatment or find a doctor or programme that will very quickly enroll you in treatment when you ask for it,” he said.Researchers are still trying to decipher a drop in overdose deaths in the US last year. They believe better treatment and prevention are playing a part. The Drug Enforcement Administration said earlier this month that the amount of fentanyl found laced into other drugs had dropped and that they were therefore less potent and dangerous. The DEA head, Anne Milgram, attributed that to the Biden administration’s targeting of Mexican cartels and their supply chains.But Kent is cautious.“There’s a lot of people running around because we’ve seen a slight reduction in overdose deaths feeling like that’s mission accomplished when we’re only losing 93,000 people versus 111,000 a year. I would never define that as success in my world. Even within those numbers, underserved communities are being higher impacted at this point. In Black and brown communities the numbers are going up while the other numbers are going down. So there’s work to be done,” he said.Kent said he agrees with the need for an increased focus on the border.“We need to increase the number of staff at the border, just for a whole bunch of reasons, including illicit drugs coming across. There needs to be an investment in screening technology. And there needs to be a continued effort with China, trying to convince China to work with its chemical companies to stop selling the chemical precursors to the Mexican cartels so they can create the fentanyl,” he said.Bisch and others whose lives have been hit by the opioid epidemic are also keen to see broader reform of a system that enabled the drug companies to push mass prescription of opioids on the public in ways not permitted in other countries.Bisch supports Trump’s nomination for attorney general, Pam Bondi, who as Florida’s attorney general cracked down on doctors and “pill mills” churning out opioid prescriptions to anyone who would pay. In 2010, Florida dispensed more opioid prescriptions than every other US state combined as people travelled from across the country to buy the painkillers in bulk. Bisch wants to see Bondi use federal laws to prosecute the drug company executives who made false claims about the safety of prescription opioids in order to get them approved.He also backs Trump’s nomination of Kennedy, who has accused the FDA of putting the financial interests of the pharmaceutical industry ahead of people’s health by effectively encouraging the prescribing of too many drugs and the selection of Marty Makary to head the FDA. Makary has said doctors in the US prescribe too many medications compared with the rest of the world.“The best way to lower drug costs in the US is to stop taking drugs we don’t need,” he told the US Senate in September.In nominating Makary, Trump said the “FDA has lost the trust of Americans and lost sight of its primary goal as a regulator”. He said Makary and Kennedy would work together to “properly evaluate harmful chemicals poisoning our nation’s food supply and drugs”.Bondi is expected to have a relatively easy path to approval by the US Senate. But Kennedy and Makary may face a more difficult time. Kennedy, in particular, will face scrutiny over his rejection of vaccines. But Kolodny said they will also be up against the pharmaceutical industry.“I’ll actually be shocked if Kennedy gets confirmed and if Makary gets confirmed for FDA commissioner because big pharma doesn’t want them, and big pharma has a lot of muscle on Capitol Hill,” he said. More

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      US overdose deaths decreased in 2023 – will Trump continue this trend?

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      The Biden administration saw unprecedented levels of US opioid overdose fatalities, but those deaths are now declining faster than they have in decades – progress a second Trump administration could continue or threaten, experts say.The number of overdose deaths in the US declined for the first time in five years in 2023, and have continued to decline more rapidly this year, according to provisional data.Some of the decline may have resulted from Biden administration efforts to expand access to harm-reduction services, especially the overdose-reversal drug naloxone, which received over-the-counter approval for the first time last year. Public health experts worry that the second Trump administration will gut access to healthcare, including addiction treatment.The president-elect’s legacy on opioids is complicated. When Trump first took office, he inherited a rapidly escalating overdose crisis. Opioid overdose deaths more than doubled during the Obama administration,according to data from the Centers for Disease Control and Prevention. The three most recent presidential administrations have all failed to quell escalating opioid overdose deaths, which nearly doubled again during the Trump and Biden administrations, dipping slightly in 2018 but overall jumping by 62% during Trump’s first term in 2020. Under Biden, deaths increased by 19% from 2020 to 2022, to 81,806, before declining by 2% last year.At times, the Trump administration seemed to work against itself when it came to the crisis. For example, Trump repeatedly attempted to gut funding for the Office of National Drug Control Policy, although Congress blocked his efforts. Similarly, Trump was frequently in disputes with Congress over attempts to repeal elements of the Affordable Care Act and its expansions to Medicaid, which funds treatment for 40% of adults with opioid use disorder.Still, experts contacted by the Guardian within and outside the first Trump administration credit the president-elect for putting unprecedented focus on the crisis.Trump signed an executive order in 2017 forming the Presidential Commission on Combating Drug Addiction and the Opioid Crisis. Bertha Madras, a professor in Harvard’s psychiatry department who served on the commission, said it wasn’t until Trump “established the commission that a significant integrated national response materialized”.Adm Brett Giroir, who served as an assistant secretary in Trump’s Department of Health and Human Services, says that he was given the authority to head up an unofficial “opioids cabinet … which met every week at the White House under Kellyanne Conway to make sure every department was working on this crisis”.Others praise Trump for supporting harm-reduction efforts, despite past opposition from his party.“President Trump publicly supported syringe services programs, a first for a Republican president,” said Jerome Adams, who served as surgeon general under Trump. Indeed, the Trump administration in some ways paved the way for the Biden administration’s response to the crisis. Access to naloxone expanded significantly under Trump, and even more under Biden.But despite these efforts, the number of US overdose deaths climbed for the majority of Trump’s first term. Giroir and Madras both attribute the huge overdose spike in 2020 to the Covid-19 pandemic, which overwhelmed the healthcare system and increased depression and suicide.Andrew Kolodny, medical director for the Opioid Policy Research Collaborative at Brandeis University, says the administration should have done more.“The first time around, President Trump did an excellent job of calling attention to the opioid crisis and designating it as a public health emergency,” he conceded, but he also said the then president failed to take sufficient action or establish a long-term plan.While the Trump administration allocated unprecedented amounts of funding to combat the crisis, Kolodny said the impact was limited, because states were usually given funds in the form of one- or two-year grants.“That’s not really adequate for building out a treatment system that doesn’t exist yet,” Kolodny said. “If you were to hire a whole bunch of staff, what would you do if you don’t get that appropriation the next year? Do you lay everybody off?”skip past newsletter promotionafter newsletter promotionExperts disagree on whether the administration spent too much of that funding on law and border enforcement, rather than treatment. Giroir supported harm-reduction and treatment expansion during his time under Trump, and is proud of his efforts to remove red tape and increase access to the opioid-cessation drug buprenorphine. Still, he says, “enforcement has to dominate the discussion”, because treatment is less effective than preventing addiction in the first place.Other experts say that criminalization only exacerbates the crisis.“Under Trump’s previous administration, they federally criminalized all fentanyl-related substances in 2018 – and overdose deaths increased from 67,367 that year to 70,630 and 93,331 in 2019 and 2020 respectively,” said Kassandra Frederique, executive director of the Drug Policy Alliance.Kolodny didn’t necessarily agree that criminalization drove the overdose increases, but he did say “the balance should be different” when it comes to prioritizing treatment over law enforcement. He said the best way to immediately reduce the overdose death count would be to make treatment “basically free” and overall easier to access than fentanyl.“[People with opioid use disorder] are not out there using fentanyl because it’s so much fun. If they don’t use, they’re gonna be very, very sick … People can really feel like they’re gonna die,” he said.It’s hard to predict how Trump will tackle the overdose crisis the second time around. He avoided the topic during his recent presidential campaign, and instead focused on inaccurate talking points about immigrants trafficking drugs across the border. He also falsely claimed he had never wanted to repeal the Affordable Care Act. But a Republican-controlled Congress could cut ACA subsidies and Medicaid.Frederique worries that Trump will continue prioritizing drug arrests during his second term, but said during his first term “he also dedicated billions of dollars toward research, education, prevention and treatment. We are committed to supporting the Trump administration’s previous efforts to advocate for health approaches such as increasing access to treatment and naloxone.” More

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      FDA approves overdose-reversing Narcan for sale without prescription

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      The US Food and Drug Administration on Wednesday approved selling naloxone without a prescription, setting the overdose-reversing drug on course to become the first opioid treatment drug to be sold over counters in the US.It is a move some advocates have long sought as a way to improve access to a life-saving drug, though the exact impact will not be clear immediately.The best-known form of naloxone is Narcan, an approved branded nasal spray made by Emergent BioSolutions in Gaithersburg, Maryland. It can reverse overdoses of opioids, including street drugs such as heroin and fentanyl and prescription versions including oxycodone.Making naloxone available more widely is seen as a key strategy to control the US overdose crisis, which has been linked to more than 100,000 deaths a year. The majority of those deaths are tied to opioids, primarily potent synthetic versions such as fentanyl that can take multiple doses of naloxone to reverse.Advocates believe it is important to get naloxone to people who are most likely to be around overdoses, including people who use drugs and their relatives. Police and other first responders often carry it.Emergent BioSolutions said Narcan would become available over-the-counter by late summer. Other brands of naloxone and injectable forms will not yet be available over the counter, but could be soon.Harm Reduction Therapeutics, a non-profit which has funding from the OxyContin maker Purdue Pharma, has an application before the FDA to distribute its version of spray naloxone without a prescription.Even before the FDA’s action, pharmacies could sell naloxone without a prescription because officials in every state have allowed it. But not every pharmacy carries it. And buyers have to pay for the medication – either with an insurance co-pay or for the full retail price. The cost varies, but two doses of Narcan often go for around $50.The drug is also distributed by community organizations that serve people who use drugs, though it is not easily accessible to everyone who needs it.Emergent has not announced its price and it is not clear yet whether insurers will continue to cover it as a prescription drug if it is available over the counter.However, the FDA decision clears the way for Narcan to be made available in places without pharmacies, including convenience stores, supermarkets and online retailers.Jose Benitez, lead executive officer at Prevention Point Philadelphia, an organization that tries to reduce risk for people who use drugs with services including handing out free naloxone, said over-the-counter access could help a lot for people who don’t seek help or who live in places where it is not available.Now, he said, some people are concerned about getting naloxone at pharmacies because their insurers will know they are getting it.“Putting it out on the shelves is going to allow people just to pick it up, not have stigma attached to it and readily access this life-saving drug,” he said.The US Centers for Medicaid and Medicare Services, which now covers prescription naloxone for people on government insurance programs, says coverage of over-the-counter naloxone would depend on the insurance program. It has not given any official guidance.Maya Doe-Simkins, a co-director of Remedy Alliance/For the People, which launched last year to provide low-cost and sometimes free naloxone to community organizations, said her group would continue to distribute injectable naloxone.One concern is whether people who buy Narcan over the counter will know how to use it, said Keith Humphreys, a Stanford University addiction expert, though the manufacturer is responsible for clear directions and online videos.One benefit of having pharmacists involved, Humphreys said, is that they can show buyers how to use it. Humphreys also said there are fears that if the drug is not profitable as an over-the-counter option, the drugmaker could stop producing it. More

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      Arresting Michael K Williams’ alleged drug dealers won’t solve the US addiction crisis | Akin Olla

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      Arresting Michael K Williams’ alleged drug dealers won’t solve the US addiction crisisAkin OllaAs a country we refuse to pursue policy reforms that might have saved the beloved actor and the many thousands of others who are dying of overdoses I cried the night Michael K Williams joined the over 100,000 Americans who died of an overdose in 2021. When I heard that Williams, the actor best known for his role as Omar, the queer, gun-toting rogue in The Wire, had suffered an accidental overdose in his apartment, I felt a deep sense of dread. The knowledge that another Black man not too dissimilar from myself had passed before his time mingled in my mind with my bitter memory of the moment when I learned that my best friend, Joseph Rodriguez, had overdosed at the age of 19.I am grateful, I suppose, that by the time Joe had died, in 2009, the public narrative around drug users had begun to evolve. Young suburban white kids had started dying, and the country quickly shifted to protect its most prized possessions. Teens were sent to rehab, and drug dealers, like those who allegedly sold Williams his final dose, were rounded up and blamed for what is clearly a broader societal issue.Last week four men in Brooklyn were charged with having sold fentanyl-laced heroin to Williams and others. This hollow act is part of the problem. The US has long chosen mass incarceration as the solution to substance abuse. Arresting people didn’t prevent Williams’ overdose, and arresting more now won’t prevent future ones. And given Williams’ stance on the war on drugs, it is doubtful he would have endorsed this action.There are many solutions that could have helped keep Williams alive. While it is unlikely that the US will rid itself of many of the underlying drivers of drug addiction – such as violence, systemic racism and the inequalities of capitalism – anytime soon, the country, and the federal government in particular, has long ignored policy reforms that could help address the worst of our current addiction epidemic. The most important reform, decriminalization, has gained steam in some places, like Oregon, but remains far away as a federal reform.Williams was a one-of-a-kind man and artist, but not unique in his struggles with drugs: according to the 2020 National Survey on Drug Use and Health, 14.5% of Americans – roughly 40.3 million people – had a substance use disorder in 2020. A couple hundred of those people die of an overdose every day. This is a long-term trend that continues to explode over time; while over 100,000 Americans died of an overdose last year, the number was roughly 17,000 in 2000. As someone who has been involved with drug policy reform since 2010, roughly a year after my friend died, it is difficult to maintain hope as the bodies pile up, especially as solution after solution is ignored by the federal government.There are an embarrassingly large number of policies that could be backed by the federal government and implemented nationwide to save lives and nudge addicted people towards healing. Rather than concentrating power in the police through criminalization, most of these policies involve treating drug users like human beings worthy of love and care. One of the simplest ways to save lives is to make drug testing kits easily available for drug users. Williams was reportedly poisoned by fentanyl, a synthetic opioid mixed into cocaine and heroin as a means for illicit manufacturers to increase profits. Drug testing kits, like fentanyl test strips, let consumers ensure that they know what they’re putting into their bodies. While these strips are available for free in some places, such as New York City, they are still illegal in many states because they’re considered drug paraphernalia.Another potentially life-saving intervention? Supervised consumption sites. These are locations where people can consume drugs safely, with the support of medical staff that can ensure the purity of what is being used while being on call to intervene in the event of accidental overdoses. These locations can also connect people with treatment services and safer alternative drugs. If this all feels unfamiliar, think of bars as a crude version of these sites: bartenders administer doses to clients and can cut them off if they are too intoxicated. If anyone drinks too much, bartenders can call an ambulance and have them hospitalized. Creating robust supervised consumption sites could save lives, and destigmatizing those sites could save even more.All of these interventions would be made more effective and possible if the federal government took the important leap to decriminalize the possession of small amounts of all drugs. Total decriminalization may seem extreme, but there is evidence that it could save lives, reduce drug use, and prevent more unnecessary incarceration and harassment of those who use drugs, particularly Black Americans. Living in New York City, Williams did have access to some harm reduction resources but, like many drug users, may have felt too much stigma to seek help.Portugal decriminalized all drugs, in small amounts, in 2001. The country has also radically expanded its capacity to treat substance use disorders. According to the US-based Drug Policy Alliance, overdose deaths in Portugal decreased by more than 80% after decriminalization. By contrast, in 2017, “there were more than 72,000 overdose deaths in the US. If the US overdose death rate were on par with Portugal’s, there would have been fewer than 800 overdose deaths that year.” By 2008, three-quarters of those suffering from substance use disorder in Portugal were in treatment.The deaths of Michael K Williams and Joseph Rodriguez were perfectly preventable if we’d wanted them to live. Addiction is inevitable in our present society. Capitalism is a system that necessarily involves the commodification of human beings and the reduction of the individual into a tiny cog that exists to work and create profit. This dehumanization, exacerbated by racism, is probably why there are strong relationships between poverty and addiction, and why Black men are now the people most likely to overdose and die.The reality is that there will be many more deaths like Williams’. I expect to lose more friends; it would be naive to think that I won’t. In recent years both Democrats and Republicans have slowly shifted closer to the kind of drug reforms that could save lives. But for some of the people I love it is too little, too late and, without a comprehensive federal plan that includes decriminalization, we may as well brace ourselves for more tearful phone calls and funerals.
      Akin Olla is a contributing opinion writer at the Guardian
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      Empire of Pain review: the Sacklers, opioids and the sickening of America

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      By 2016, opioids had torn a piece out of Appalachia and the rust belt. The deep drop in life expectancy among white Americans without four-year degrees would no longer be ignored. OxyContin, Purdue Pharma’s highly addictive painkiller, helped elect Donald Trump.In Empire of Pain, Patrick Radden Keefe methodically and meticulously chronicles this tale of woe and crisis, indifference and corruption. His Secret History of the Sackler Dynasty lays bare the price exacted by the family’s drive for wealth and social mountaineering.The Sackler name came to dot the Metropolitan Museum of Art, the Smithsonian, Tate Modern and the Louvre. They rose – others paid dearly.Keefe is a veteran writer at the New Yorker. His 2019 bestseller, Say Nothing, chillingly examined the convergence of youth, zealotry and destruction in Northern Ireland. He even solved the mystery behind a disappearance.Like Say Nothing, Empire of Pain is drenched in misery, this time the byproduct of OxyContin, the go-to drug for Purdue. Since 1999, opioid-related deaths have risen more than fivefold. By the numbers, opioids have killed more than 450,000 in the US in two decades.Keefe’s book builds upon The Family that Built an Empire of Pain, a 2017 long read. Empire of Pain is filled with firsthand interviews and takeaways from confidential and original documents. It is a chilling and mesmerizing read, “substantially built on the family’s own words”. Which is what makes it so damning.The Sacklers did not cooperate. Indeed, they sought to derail publication. Keefe raises the possibility he was placed under surveillance, an attempt to intimidate him and his family. Nonetheless, the Sacklers’ indifference and smugness rise off the pages like steam from a sewer.In one 1996 email, Richard Sackler, Purdue’s chairman and president, demands the company become as feared as a “tiger with claws, teeth and balls”. Asked repeatedly at deposition years later if Purdue played any role in the opioid crisis, he steadfastly answers: “I don’t believe so.”A cousin, Kathe Sackler, actually boasts that OxyContin was a “very good medicine” and a “safe medicine”. She also claims credit for coming up with the “idea”. But she doesn’t end there.Confronted with the question, “Do you recognize that hundreds of thousands of Americans have become addicted to OxyContin?”, she can only muster: “I don’t know the answer to that.”The drumbeat surrounding the monster birthed by Purdue is as old as the century itself. Barry Meier, then of the New York Times, published Pain Killer: An Empire of Deceit and the Origin of America’s Opioid Epidemic, in 2003.Yet faced with pushback from Purdue and the Sacklers, the powers that be swept the crisis under the rug. Even the Times came down with a case a temporary case of cold feet.In 2007, under George W Bush, the US justice department only delivered a relative slap on the wrist. The Sacklers, major Republican donors, had unleashed a full-scale counter-attack starring Rudy Giuliani, Mary Jo White, formerly in charge of the southern district of New York and the Securities and Exchange Commission, and a bevy of high-priced legal talent.Strings were seemingly pulled, career prosecutors’ findings and recommendations discounted and binned. Purdue agreed to pay $600m to resolve a felony charge of misleading and defrauding physicians and consumers. Three executives entered guilty pleas and agreed to $34.5m in penalties. None of the individuals criminally charged were Sacklers.In the words of a former DoJ lawyer, this was “a political outcome that Purdue bought”. The company named its in-house law library after one of the designated-offenders and paid millions in post-employment compensation: a reward for taking a bullet for the team.Paul McNulty, then deputy attorney general, helped handcuff justice. John Brownlee, the federal prosecutor for the western district of Virginia, clashed with McNulty over the disposition of the case. Word spread that Brownlee’s job tenure was shaky. He resigned in April 2008. For the record, James Comey, McNulty’s predecessor as deputy AG, resisted Purdue’s entreaties.Among hundreds of interviews, Keefe spoke to Brownlee and Rick Mountcastle, the line prosecutor and career lawyer who handled the case. Still at DoJ, Mountcastle raises the possibility Purdue had an inside man at the Food and Drug Administration who enabled OxyContin in exchange for the prospect of future employment.Based on a 1995 email, Mountcastle began to suspect that Curtis Wright, then an FDA examiner, had turned a blind eye to the dangers posed by OxyContin. Purdue would later tap Wright to be an executive director. In 2003, Wright testified that he still believed addiction to OxyContin was “rare”.“I think there was a secret deal cut,” Mountcastle tells Keefe. “I can never prove it, so that’s just my personal opinion. But if you look at the whole circumstances, nothing else explains it.”Regardless, the FDA helped pave the way for an opioid epidemic. Dr David Kessler, FDA commissioner when OxyContin received the agency’s approval, acknowledged “certainly one of the worst medical mistakes”.Donald Trump spoke of the toll of the opioid crisis but in 2020, as election day loomed, his Department of Justice announced a “global resolution” of the government’s investigation into Purdue and the Sacklers. By then, the company was in bankruptcy and the target of a barrage of civil lawsuits.The Sacklers agreed to pay a $225m civil penalty, little more than the 2% they had taken from Purdue. But no one would be prosecuted. Asked why the government had not brought criminal charges against the Sacklers, Jeffrey Rosen, Bill Barr’s deputy attorney general, declined to say.The government, Keefe writes, was “so deferential toward the Sacklers that nobody even bothered to question them”. More