officials in everett, washington, filed a lawsuit against purdue pharma, the manufacturer of oxycontin, for negligence by first, allowing and also failing to prevent drugs being illegally trafficked to city residents. the city wants the company to pay the costs of handling the crisis. west virginia in west virginia, leading the nation in overdose deaths per capita, lawsuits sought to declare drug distribution companies a "public nuisance" in an effort to place accountability upon the drug industry for the costs associated with the epidemic. on may 3, 2021, the city of huntington filed a lawsuit against three major drug manufacturers accusing them of their role in stoking the opioid crisis through their excessive shipment of painkillers. massachusetts the massachusetts taxpayers' foundation published a report which contains an analysis of the economic impact of the opioid epidemic in massachusetts. in 2017, the state lost a total of $15.2 billion. out of that total, at least $5.5 billion was dedicated to funding opioid-related services; and $9.7 billion was lost as a result of losses in productivity as 32,687 people were kept out of the workforce due to opioids. the report also analyzes forgone wages due to deaths related to opioid overdoses accounted for over $1.1 billion in losses from 2015 to 2017. therefore, the total amount lost taking into account forgone wages and lost productivity is about $7 billion per year. the social effects of the opioid epidemic include the costs associated with healthcare and the criminal justice system. in regards to healthcare, costs can be attributed to neonatal abstinence syndrome treatment and emergency services. neonatal abstinence syndrome or nas occurs when a woman abuses opioids during pregnancy, thus causing the baby to experience withdrawal symptoms when born. according to the national institute on drug abuse, in 2017 out of every 1000 hospital births, 13.7 of those births involved an infant born with nas. additionally, the responses to opioid related incidents involve costs related to narcan, transport to the hospital, and first responders. in 2016 and 2017, the total cost of all these factors was $43 million. meanwhile, in patient and icu costs were $538 million and $271 million, respectively. in regards to the criminal justice system, a report from the massachusetts health policy forum states that the effect of the opioid issue on the criminal justice system is estimated to be $500 million. the middlesex sheriff's office notes that of the 73% of the prisoners with alcohol or drug addiction are involved in opioids. the analysis by the massachusetts taxpayers' foundation notes that handling prisoners battling opioid use disorders costs $470 million each year. legal action in may 2019, in the first successful prosecution of top pharmaceutical executives for crimes related to the prescribing of opioids, the founder and four former executives of insys therapeutics inc. were convicted by a federal jury in boston in connection with bribing medical practitioners to prescribe subsys, a highly-addictive sublingual fentanyl spray intended for cancer patients experiencing breakthrough pain, and for defrauding medicare and private insurance carriers. the company declared bankruptcy about two weeks after they lost the case. dozens of states are suing pharmaceutical companies, accusing them of causing the epidemic. suits filed by almost 2,000 cities, counties, and tribal lands have been rolled into a single federal case scheduled to be heard in fall 2019. in the first state case to reach a decision, on august 26, 2019, oklahoma district court judge thad balkman found the pharmaceutical company johnson & johnson responsible for creating a "public nuisance" under state law, and ordered the company to pay a fine of $572 million. the company said they will appeal. two other drug makers had previously settled with the state of oklahoma. purdue pharma, the maker of oxycontin, agreed to a fine of $270 million in march 2019, and teva pharmaceuticals, which makes generic drugs, agreed to pay $85 million in may. ohio jury trial on october 4, 2021, a landmark trial began in a cleveland court. the defendants are pharmacy chains and operators, including walmart, walgreens and cvs. these chains are accused of not having enough trained staff and sophisticated systems to responsibly dispense opioids. lawyers allege that pharmacies have not fulfilled their legal responsibility to act as a "last line of defense,” and that the chains enable illegal street dealing of prescription opioids. lake and trumbull counties in northeast ohio were the plaintiffs and alleged the chains had “substantially contributed to the crisis of opioid overdose and deaths….” in the counties. in november 2021, a 12-person jury, after five and a half days of deliberation, held the retailers accountable for contributing to a “public nuisance.” this was the first jury verdict in the decades-long crisis. the retailers said they would appeal the jury's verdict. on august 17, 2022, cvs, walgreens and walmart were forced to pay out $650.5 million to lake and trumbull county. states reject distributors’ settlement in february 2020, 21 us states turned down an $18 billion (us), 18-year offer from mckesson, cardinal health inc. and amerisourcebergen corp. that would have resolved litigation against the pharmaceutical companies over their distribution of the addictive painkillers. a letter from the attorneys general of ohio, florida and connecticut (among others) said the settlement, as “currently structured,” was not acceptable to the states. this particular offer was part of the proposed $50 billion (us) agreement to find a resolution to over 2,000 lawsuits from both local and state governments attempting to recoup billions of dollars they have spent combatting the crisis. july 2021 settlement four major drug manufacturers and distributors, j&j, mckesson, cardinal health, and amerisourcebergen, have agreed to a settlement announced by a group of state attorneys general in july 2021. the settlement, $26 billion (us), will be used on the prevention of opioid addiction and treatment programs. j&j will pay $5 billion (us) over the next five years; the remaining $21 billion (us) will be paid by the other firms. the settlement, when approved by a "significant" group of states and local governments, will settle more than 4,000 individual legal actions. all four of the manufacturing firms disputed all allegations in the lawsuits. cleveland settlement the united states’ three largest pharmaceutical distributors, amerisourcebergen, cardinal health and mckesson reached an agreement in october 2019 where they will pay two ohio counties a combined us$215 million. as part of the deal, israel drug manufacturer teva will also provide us$20 million in cash and us$25 million worth of suboxone, an opioid addiction treatment. cuyahoga county (cleveland) and summit county (akron) brought the suit in us federal district court (northern district of ohio). the settlement averted what would have been the first federal trial over the us opioid crisis. the defendants offered no admission of wrongdoing. more than 2,600 lawsuits against the us pharmaceutical industry are still in the offing. the plaintiffs in those cases said the ohio settlement allows them time to attempt to negotiate a national settlement. it also pressures the participants to work out a deal, as every partial settlement diminishes the aggregate total the companies will be able to pay. the two counties had reached a similar settlement of us$20.4 million with johnson & johnson and its subsidiary ethicon, inc. earlier in october 2019. homicide by overdose homicide by overdose is the act of giving someone a specified controlled substance which causes that person to die. they are considered an easy way to murder an addict as no one will suspect it's anything but a routine overdose. however states are charging people even when the overdose was unintentional. as of 2019, half of all us states have "homicide-by-overdose" or "drug-induced homicide" (dih) laws. while these laws date back to the 1980s, they were originally used infrequently. prosecutions dramatically increased in the 21st century. (in 2000, there were 2 prosecutions; in 2017, there were 717 prosecutions.) in 2017, legislators in at least 13 states introduced bills to enhance these laws or create new ones. prescription drug monitoring in 2016, the cdc published its "guideline for prescribing opioids for chronic pain", recommending opioids only be used when benefits for pain and function are expected to outweigh risks, and then used at the lowest effective dosage, with avoidance of concurrent opioid and benzodiazepine use whenever possible. silvia martins, an epidemiologist at columbia university, has suggested getting out more information about the risks:the greater "social acceptance" for using these medications (versus illegal substances) and the misconception that they are "safe" may be contributing factors to their misuse. hence, a major target for intervention is the general public, including parents and youth, who must be better informed about the negative consequences of sharing with others medications prescribed for their own ailments. equally important is the improved training of medical practitioners and their staff to better recognize patients at potential risk of developing nonmedical use, and to consider potential alternative treatments as well as closely monitor the medications they dispense to these patients. as of april 2017, prescription drug monitoring programs (pdmps) exist in every state. a person on opioids for more than three months has a 15-fold (1,500%) greater chance of becoming addicted. the cdc's "guideline for prescribing opioids for chronic pain" offers many non-pharmacological options as alternatives to prescribing opioids. physical therapist interventions is an example that is offered in regards to an alternative to prescribing opioids. pdmps allow pharmacists and prescribers to access patients' prescription histories to identify suspicious use. however, a survey of us physicians published in 2015 found only 53% of doctors used these programs, while 22% were not aware these programs were available. following the implementation of pill mill laws and prescription drug monitoring programs in florida, there was a large decline in opioid prescriptions written by high-risk prescribers (those prescribing the top 5th of opioids by volume). the centers for disease control and prevention (cdc) was tasked with establishing and publishing a new guideline, and was heavily lobbied. a 2018 study by the university of florida concluded that there is little evidence that drug-monitoring databases are having a positive effect on the number of drug overdoses in the us. researcher chris delcher also concluded that "there was a concurrent rise in fatal overdoses from fentanyl, heroin and morphine" due to ease of availability and lower cost following prescription drug crackdowns. the american medical association (ama) has created an opioid task force for helping physicians to combat the epidemic. the ama has suggested 6 actions for physicians to take: register and use state prescription drug monitoring programs enhance education and training support comprehensive treatment for pain and substance use disorders help end stigma co-prescribe naloxone to patients at risk of overdose encourage safe storage and disposal of opioids and all medications. the opioid task force 2018 progress report states that between 2013 and 2017 opioid prescriptions have decreased by 22.2%, which includes a 9% decrease from 2016 to 2017 alone. the ama opioid task force also reports a 389% increase in physician participation in pdmps. further, physicians are encouraged to co-prescribe naloxone to those at risk of overdose. in 2017 alone, weekly filled naloxone prescriptions have doubled from 3,500 to 8,000 and more than 50,000 physicians were certified in 2017 to provide in-office buprenorphine. patrice a. harris, chair of the ama opioid task force, urges increased participation by physicians, saying "what is needed now is a concerted effort to greatly expand access to high quality care for pain and for substance use disorders. unless and until we do that, this epidemic will not end." in the media media coverage has largely focused on law-enforcement solutions to the epidemic, which portray the issue as criminal, whereas some see it as a medical issue. there has been differential reporting on how white suburban or rural addicts of opioids are portrayed compared to black and hispanic urban addicts, often of heroin, reinforcing stereotypes of drug users and drug-using offenders. in newspapers, white addicts' stories are often given more space, allowing for a longer backstory explaining how they became addicted, and what potential they had before using drugs. in early 2016 the national desk of the washington post began an investigation with assistance from fired drug enforcement administration regulator joseph razzazzisi on the rapidly increasing numbers of opioid related deaths. while media coverage has focused more heavily on overdoses among whites, use among african, hispanic and