Twenty years ago, four major U.S. tobacco companies paid $206 billion for misleading the American public about the dangers of smoking under the Tobacco Master Settlement Agreement of 1998. As tobacco companies have had to help pay for the cancer, emphysema, and other public health crises they helped cause by aggressively marketing dangerous products, it is now time for opioid manufacturers to pay their fair share for contributing to the opioid pandemic in our country.

For decades, manufacturers of pain medications — like Purdue Pharma, which makes Oxycontin — have knowingly relied on unscrupulous evidence to undersell the risks of opioids to doctors and the public alike. They have often cited dubious sources, like a now-infamous 1980 letter to the editor of the New England Journal of Medicine in which the authors claimed that less than one percent of people treated with narcotics become addicted. Meanwhile, millions of Americans have become addicted and many thousands have died from overdoses of opiate-based pain medications and their illicit, less expensive analog, heroin.

Estimates of the societal cost of opioid addiction and related deaths put the figure at $193 billion. In our state alone, opioids have claimed the lives of 2,400 Marylanders just this past year.

Yet after causing millions to become addicted and making billions of dollars in the process, pharmaceutical companies have not repaid their debt to society. Anne Arundel County’s lawsuit against opioid manufacturers, distributors and prescribers, is likely to be one of many targeting these companies for the reckless endangerment they have been engaging in for years.

If there are settlement monies from these lawsuits, the funds should be used to address the opioid overdose crisis at three different levels: upstream, midstream and downstream.

Upstream approaches prevent people from falling into the river of addiction in the first place by investing in efforts to decrease inappropriate prescribing of opioids. This can be done by integrating prescription drug monitoring databases into electronic health records, so prescribers can ensure people are not receiving multiple prescriptions. It can also be accomplished by mandating better insurance coverage for non-opioid therapies and creating educational opportunities for prescribers to keep up with evidence-based guidelines and recognize the signs of addiction.

Midstream approaches help treat people who are already struggling with addiction by preventing them from overdosing — going over the waterfall’s edge. According to the Behavioral Health Systems of Baltimore, 7,300 people in our city who need it do not have access to medication-assisted treatment like methadone, suboxone or naltrexone. We need more prescribers to provide these therapies so those living with addiction can remain functional, contributing members of society. We need to maintain supervised injection facilities and needle-exchange vans to provide active users with clean supplies and safe environments so they don’t acquire HIV, Hepatitis C or skin infections, while also offering to connect people with immediate detox options. When people can’t afford or access oxycodone, that’s when they often turn to heroin as the cheaper alternative. Finally, midstream approaches require adequate investments in law enforcement to reduce heroin trafficking.

Downstream approaches prevent people from dying from an overdose. These include investing in expanded access to the antidote naloxone, including Uber-like apps that alert naloxone carriers nearby of an overdose so they can intervene. Unfortunately, this medication is a paper life preserver: It dissolves in 15 minutes, leaving the recipient at risk of further decline unless treated immediately by health care professionals. Still, such emergency interventions are crucial to treating the hundreds of overdoses that happen each year in our city.

The severity of this crisis requires bold, evidence-based approaches, and it is time to get all hands on deck. If the pharmaceutical companies who put people’s lives at risk by aggressively marketing dangerous products don’t voluntarily pitch in to fund sensible solutions, then the courts who hear cases brought by cities, counties and state attorneys general against opioid manufacturers should settle in favor of the victims whose lives have been torn apart by negligence and greed.

Dr. Richard Bruno (Twitter: @RichardBrunoMD) is a family physician treating the uninsured in Baltimore. He is a Democratic candidate for state delegate in District 41.