(CNN) Missouri has filed suit against three pharmaceutical companies for allegedly violating the state's Medicare fraud and consumer-protection statutes by "misrepresenting the truth" about opioids, Attorney General Josh Hawley said Wednesday.
The companies named in the suit are Purdue Pharma, Endo Pharmaceuticals, and Janssen Pharmaceuticals.
"These companies knew that the drugs they sell and market are highly addictive, even life-threatening if misused. And yet they have engaged in a deliberate campaign of fraud to convince Missouri doctors and Missouri consumers otherwise.
"They used bogus front organizations and fake research; they used fraudulent advertising and deceptive trade practices. And they repeatedly lied about the risks and true nature of the drugs they sold," Hawley said at a news conference. "Their fraud has been devastating."
Opioids: Addictive painkillers
Prescription and illegal opioids are commonly abused because they are so addictive.
Opioid medications bind to the areas of the brain that control pain and emotions, driving up levels of the feel-good hormone dopamine in the brain's reward areas and producing an intense feeling of euphoria.
As the brain becomes used to the feelings, it often takes more and more of the drug to produce the same levels of pain relief and well-being, leading to dependence and, later, addiction.
Oxymorphone hydrochloride, under the name Opana ER, was at the center of an HIV outbreak in Indiana in 2015. Some addicts began injecting and shared needles increased the spread of HIV.
In June, the Food and Drug Administration requested that Opana ER manufacturer Endo Pharmaceuticals pull the drug from the market. It was the first time the agency has asked that a opioid pain medication be pulled "due to the public health consequences of abuse." Endo announced in July that it would pull the drug.
Codeine is one of the weakest opioids, often given when painkillers such as acetaminophen or ibuprofen fail to work. Because it decreases activity in the part of the brain that controls coughing, it's frequently mixed with other liquids to develop cough syrups for colds and flu. It has frequently been used for pain relief after removal of tonsils and adenoids in children.
After an investigation, the FDA restricted the use of codeine and tramadol in children under 12 and recommend against their use in children between 12 and 18 years of age. Additionally, the FDA has warned breastfeeding mothers not to take these medications due to the risk of serious adverse reactions in breastfed infants.
You can't get heroin by prescription, but many heroin users start off abusing prescription opioids, then turn to this illegal opioid.
CNN's Chief Medical Correspondent Dr. Sanjay Gupta
has reported on recent research that shows today's typical heroin addict starts using at 23, is more likely to live in affluent suburbs and was likely unwittingly led to heroin through painkillers prescribed by his or her doctor.
According to the CDC, deaths from overdoses of prescription drugs and heroin continue to be the leading cause of unintentional death for Americans, rising 14% from 2013 to 2014.
Fentanyl citrate, pictured here, is a Class II controlled substance and one of the most powerful opioids on the market. It's often administered via injection or transdermal patch, or in lozenge form for pain after surgery, for difficult-to-manage chronic pain and for people who have developed a tolerance to other opioids.
The type of fentanyl usually associated with overdoses is bought on the street in powder or pill form and is often mixed with heroin in a clandestine lab to increase the high it produces. Street names include Apache, China girl, goodfella, jackpot, murder 8, TNT and Tango and Cash.
These pills are a more powerful form of codeine, called hydrocodone, and are often mixed with acetaminophen. Hydrocodone is the most frequently prescribed opioid painkiller,
according to the U.S. Food and Drug Administration, and the most abused. An overdose of hydrocodone can cause "cold and clammy skin, severely constricted pupils, and slow breathing that can lead to a loss of consciousness and death."
Oxycodone is a powerful narcotic pain reliever prescribed for moderate to high pain relief. It's often given in an extended-release formula for patients who will need to be on pain medications for long periods of time.
Patients are warned not to break, chew, crush or dissolve extended-release tablets because the rush of oxycodone into the system could cause serious health problems, including overdose and death.
Though highly addictive, oxycodone is not thought to be as frequently abused as hydrocodone. OxyContin, Percocet, Percodan and Tylox are some trade-name oxycodone products.
Morphine is another powerful opioid often administered via syringe for severe pain. It can come in pill form, usually as extended-release tablets and capsules, and is prescribed only to relieve difficult, chronic pain that cannot be controlled by the use of other pain medications.
As with most opioids, mixing medications, drinking alcohol or taking other meds that contain alcohol, or using street drugs while taking morphine, increases the risk of breathing problems or other serious, life-threatening side effects.
Meperidine is another narcotic analgesic, similar to morphine. It's often used to help put people to sleep before an operation and to provide pain relief after childbirth.
The most common brand name is Demerol, which comes in both tablet and liquid forms. It is usually taken with or without food every three or four hours as needed for pain.
As with all opioids, meperidine can cause drowsiness, so never drive a car or operate machinery after taking it until you know how you will react.
Hydromorphone is another highly potent prescription painkiller. It's most commonly known by the brand names Dilaudid, pictured here, and Exalgo.
Liquid hydromorphone holds the dubious honor of being
frequently mistaken for morphine in hospital "wrong drug" medication errors because of the similarity of the names and appearances.
Though methadone is used to relieve severe chronic pain, it's most commonly known for preventing withdrawal symptoms in patients who were addicted to opioid drugs, as a part of their recovery process.
Methadone has many of the same side effects as other opioids, including weakness, headache, nausea and vomiting, stomach pain, sweating, difficulty urinating, mood changes and vision problems, and difficulty falling asleep or staying asleep.
Buprenorphine is a opioid used as an alternative to methadone to help addicts recovering from heroin use. Buprenorphine is different from other opioids because it's a "partial opioid agonist," which means that when taken in proper prescribed doses, it should produce less euphoria and physical dependence, and therefore a lower potential for misuse. It's also supposed to have a relatively mild withdrawal profile.
However, if abused by crushing and snorting or injecting, it can suppress breathing and cause dizziness, confusion, unconsciousness and death.
Subutex, the brand name for buprenorphine, is taken as a tablet placed under the tongue and allowed to dissolve.
The brand Suboxone is a combination of buprenorphine and naloxone, an opioid antagonist. Antagonists block the opiate receptors in the brain, keeping the narcotic from creating the high abusers crave.
States investigate opioid manufacturers
Hawley says 500 Missourians died of opioid overdoses or complications and 300 more died from heroin misuse in 2015.
"In 2012, physicians wrote some 259 million opiod prescriptions in the United States -- that's 10 million more prescriptions than there are adults living in the United States of America," he said.
Companies respond to lawsuit
The three manufacturers named in the suit responded to its announcement Wednesday.
While Endo Pharmaceuticals said it was company policy not to comment on current litigation, it did put out a statement.
"At Endo, our top priorities include patient safety and ensuring that patients with chronic pain have access to safe and effective therapeutic options. We share in the FDA's goal of appropriately supporting the needs of patients with chronic pain while preventing misuse and diversion of opioid products," the statement said.
Purdue Pharma denied the allegations in the lawsuit and said it was an "industry leader" in abuse-deterrent technology.
"While we vigorously deny the allegations in the complaint, we share the attorney general's concerns about the opioid crisis and we are committed to working collaboratively to find solutions. OxyContin accounts for less than 2% of the opioid analgesic prescription market nationally, but we are an industry leader in the development of abuse-deterrent technology, advocating for the use of prescription drug monitoring programs and supporting access to Naloxone -- all important components for combating the opioid crisis," Purdue's statement said.
Janssen Pharmaceuticals spokeswoman Jessica Castles Smith said the company recognizes that "opioid abuse is a serious public health issue. Janssen has acted appropriately, responsibly and in the best interests of patients regarding our opioid pain medications, which are FDA-approved and carry FDA-mandated warnings about the known risks of the medications on every product label."
Hawley was joined at the news conference by a mother who lost her teenage daughter to opioid addiction and a man recovering from opioid abuse.
Hawley said beyond "seeking one of the largest judgments in Missouri history," he wants to implement "anti-addiction programs and public awareness education" as well as "rehabilitation opportunities and job training."
Previous suits filed
The Missouri suit follows a filing by Ohio suing five drug companies, accusing them of fueling the opioid crisis there by misleading doctors about the risks of addiction.
In adddition to those actions, counties and cities across the country have begun filing lawsuits against manufacturers over their roles in the drug epidemic. In Cabell County, West Virginia a complaint was filed (PDF) earlier this month alleging that between 2007 and 2012, drug companies and distributors, including pharmacies such as Walgreen's and Rite Aid, sold nearly 40 million doses of prescription opiates such as hydrocodone and oxycodone to county pharmacies.
The county population during those years grew from just over 94,000 to just over 96,000 people. Similarly, nearby Kanawha County, West Virginia, filed a lawsuit (PDF) at the same time alleging the drug companies sold 66 million doses of these medications during the same time period when the county population ranged from about 191,000 to 192,000 residents."
Earlier this month several state attorneys general announced an initiative to investigate what role manufacturers may have played in contributing to the opioid epidemic.