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Recommendation 7a: To avoid repeating the experience with the tobacco industry responding to increased regulation in developed countries by finding new markets overseas, the USA and other developed nations in which opioid manufacturers are based should extend restrictions and legal sanctions on companies and owners to their global operations.

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     Government entities in the USA have won significant civil cases against U.S. based manufacturers and distributors. In addition to securing damage settlements, these cases have curtailed some deceptive practices that helped trigger the epidemic, such as misleading prescribers by overstating the benefits and understating the risks of prescription opioids, making secret payments to key opinion leaders who promote their products, and engaging in false advertising.

      However, these court decisions and legal agreements do not prevent companies or their owners from engaging in the same fraudulent conduct outside the USA. A vivid case in point concerns the activities of the Sackler family, which owns both the USA-based company Purdue Pharma and a sister company, Mundipharma, which is active internationally. Purdue Pharma executives were found criminally and civilly responsible for its destructive and fraudulent tactics promoting OxyContin in the USA in 2007, and the company itself was found criminally and civilly liable in another major case in 2020. Purdue Pharma will go out of existence as a result of the most recent case, but this is no barrier to the Sackler family carrying on the same activities international through another company. 

     Political officials are fundament responsible for the well-being of their own citizens, but still have an ethical imperative is to protect people in other nations as well. They should therefore insist on legal settlements with the opioid industry in which fraudulent and dangerous practices are banned not only for the domestic market but for the international market as well, including through subsidiaries or other companies with the same owners. Otherwise epidemics of prescription opioid use disorder and overdose could become pandemic. This concern has particular urgency given the latest federal and state prosecutions against Purdue Pharma and the Sackler family, in which forcing the family to give up foreign sister companies like Mundipharma (as well as Napp Pharmaceuticals) is being considered. Preventing the family only from continuing fraudulent OxyContin promotion domestically while allowing them to do so overseas through a different company would be a terrible failure of leadership.