The next 12 months might just redefine the way America thinks about and responds to the opioid epidemic that now claims more than 40,000 lives each year. The nation’s biggest drugmakers and distributors face a wave of civil lawsuits that could total tens of billions of dollars in damages.

Thousands of state and local governments, including cities and tribal governments, are demanding that companies like Purdue Pharma, Walmart and Rite-Aid compensate them for the costs of responding to the crisis. They’re also pushing companies to reveal far more internal documents, detailing what they knew about the risks of prescription pain medications.

“Our next battle is to get the documents that are being produced made available to the public instead of everything being filed under confidentiality agreements so we can get the facts out,” said Joe Rice, an attorney representing local governments suing the drug industry.

How we got here

Some of that internal information could be explosive, changing the way America views the opioid crisis. We know already that in the 1990s there was growing pressure in the health care industry to treat pain more aggressively. Purdue Pharma created a game-changing, long-acting opioid called Oxycontin. The company marketed the drug aggressively to doctors as a safe medication that provided long-term relief.

“In fact, the rate of addiction amongst pain patients who are treated by doctors is much less than one percent,” claimed one of the company’s advertisements at the time, aimed at convincing skeptical physicians. “These drugs should be used much more than they are for patients in pain.”

In their lawsuits, local and state governments claim that dozens of companies — including drugmakers, suppliers and pharmacies — made billions of dollars flooding the U.S. with a variety of prescription pain pills. Critics also say there was a concerted effort by firms to mislead the public and physicians about the dangers.

One of the arguments being made is that pharmacies and drug distributors, including Walgreens, Walmart and CVS, knew that they were selling too many pills, helping to create dangerous levels of addiction and a new black market.

We now also know that the public health risk was severe.

Since 1999, millions of Americans have abused prescription opioids. The federal government reports that more than 130 people now die each day from opioid overdoses, though not all of those drugs were obtained by prescription.

The growing number of people who became addicted also overwhelmed many government agencies, from law enforcement to drug rehab clinics to foster care programs. That’s where a lot of these lawsuits come in. Thousands of local and state governments, tribes and cities argue that companies should pick up the tab for battling the epidemic.

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“We are still in the throes of a public health crisis in Summit County,” said Greta Johnson, a county official helping to coordinate the response in Akron, Ohio. She argued that the drug industry should be financially responsible for programs designed to ease the suffering in communities like hers. “We’re confident the court will see it that way as well.”

Paying the price for recovery

Public officials hope for an outcome similar to the massive tobacco settlement of the 1990s. Cigarette-makers have paid out more than $100 billion over the past 20 years to compensate Americans for high rates of illness and public health costs tied to smoking. Some of that money went to programs aimed at helping smokers quit.

Local and state officials say they desperately need that kind of cash settlement to solve this crisis. A lot of the worst opioid abuse is happening in poor, cash-strapped communities. A settlement worth tens of billions of dollars could revolutionize the national response, creating more drug rehab programs, detox beds, and more training for first responders.

Many claims will be tossed

NPR talked with experts who predicted that many of the specific claims in these lawsuits will eventually be tossed out for technical legal reasons. In court filings, companies have argued that local and state governments are the wrong entities to seek financial damages from the epidemic and that statutes of limitations have expired in many jurisdictions.

The industry has also argued that the epidemic was caused by numerous factors, including the actions of government regulators and policymakers, suggesting that firms profiting from opioid sales shouldn’t be held liable for misuse. They’ve also changed their marketing strategies in response to escalating rates of addiction.

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“Earlier this year we ended our practice of promoting opioid medications to prescribers through sales representatives,” Purdue Pharma announced on its website in 2018.

But legal scholars following these cases say evidence has emerged already that suggests significant wrongdoing by some of these companies, which could leave them vulnerable financially.

“The judge has made it clear that he wants a settlement ultimately from this, along the lines of the tobacco settlement,” said Richard Ausness, a law professor at the University of Kentucky who follows these cases closely. “If that is indeed the way that he feels, he is probably not going to let the defendants off the hook.

He was referring to Judge Dan Polster, whose federal court in Ohio is handling one of the largest test cases, which includes hundreds of consolidated lawsuits. Last month, Polster referred to the opioid crisis as a “man-made plague,” but so far no national settlement has materialized.

That sets the stage for big court fights around the country over the next year.

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Like many kids, Lisa Sparrell’s daughter never liked getting shots at the doctor’s office. “At first she’d cry some, but was quickly placated with rewards like a lollipop or a sticker,” says Sparrell, who lives in Honolulu.

But last year, Sparrell’s 10-year-old daughter was diagnosed with a heart defect. In preparation for surgery, the little girl’s trips to the doctor sharply increased –and so did her anxiety.

“The frequency of appointments — many of which included blood draws and IV placements — made her fears worse,” Sparrell says.

The concerned mom tried bringing electronics and books to medical appointments, hoping distraction might short-circuit her daughter’s fear. She also tried addressing the worries by asking the child, ahead of appointments, “OK, what’s our plan?”

None of these tactics worked. In fact, her daughter’s medical anxiety became so severe that she’d scream, “Please don’t do this to me!” whenever a health care provider tried to prick her with a needle.

That might sound extreme, but results of a nationally representative survey, released earlier this year by researchers at the University of Michigan, suggest that a significant number of young children fear doctor visits. In fact, of the 726 parents surveyed, roughly half said their kids disliked going to the doctor.

Not surprisingly, 66 percent of children between the ages of 4 and 5 hated getting shots, while 43 percent of 2- and 3-year-olds fear doctors as part of a more generalized stranger anxiety. The report also revealed that 1 in 25 parents surveyed had postponed a vaccine appointment because of their child’s medical anxiety.

Sparrell says she can relate. “When my daughter screams at the doctor’s office, I feel like I’m doing something terrible — even though it’s the right thing to do.” She, too, has delayed getting her daughter vaccinated against the flu this year, Sparrell admits, just to avoid that stress.

Seeing their child unhappy upsets many parents, especially when they can’t stop the pain. And witnessing an anxious kid’s tears and pleas to avoid getting pricked and probed can raise a parent’s anxiety levels, too.

When this happens, says Sasha Albani, a child and adolescent psychotherapist in San Francisco, many well-meaning parents either ignore the wails or jump into rescue mode. Both approaches can boomerang.

“Parents may avoid discussing the problem because they believe it will make things worse,” Albani says. “Sometimes, they cancel their child’s medical appointment.” Unfortunately, these behaviors undermine a child’s confidence that they can weather difficult situations, and only reinforce kids’ worries.

Children who withdraw from frightening situations or environments may be more likely to struggle with social anxiety, later in life, psychologists find. A 2018 report released by the Child Mind Institute suggests that untreated anxiety also can lead to depression, academic difficulties and substance use down the road.

But there’s hope! Albani suggests parents calm themselves and find age-appropriate ways to help children face their medical fears instead of fleeing them.

For very young kids, who have a hard time putting words to thoughts and emotions, imaginary play with mom or dad before the appointment can help, Albani says.

“Use a toy doctor kit to explain what will happen at the appointment and to discuss your child’s specific worries,” she advises.

Reading books and watching movies depicting children getting shots, going to the hospital, or visiting the doctor can remind kids they’re not alone, and introduce different ways of dealing with the anxiety.

Children under age 6 may benefit from the book, “Daniel Visits the Doctor” by Becky Friedman.

Kids with needle phobias may be helped by reading, “Lions Aren’t Scared of Shots: A Story for Children About Visiting the Doctor,” by Howard S. Bennett. And the book “Imagine a Rainbow: A Child’s Guide for Soothing Pain,” by Brenda S. Miles, may be useful for older kids between the ages of 8 and 10.

Playing The Coping Skills Board Game can bolster the confidence of preteens like Sparrell’s daughter, as it teaches techniques for handling life’s challenges. And smartphone apps like “Stop, Breathe & Think Kids” can be a fun way to learn mindful breathing techniques and other relaxation tips that help turn down the alarm of worrisome feelings.

Doctors have also had some success using more novel interventions with kids, like virtual-reality technology, says Dr. Tom Caruso, a pediatric anesthesiologist at Lucile Packard Children’s Hospital Stanford in Palo Alto, Calif.

“Virtual-reality technology can redirect a child’s attention by immersing them in a more calming experience,” says Caruso, who co-founded the hospital’s Chariot Program, a group dedicated to reducing the anxiety of hospitalized children.

Hospitals and clinics already have begun testing VR to soothe kids’ fears during a range of medical procedures, including IV placement, blood draws and vaccines. A 2017 review suggests the approach lessens pain and anxiety by diverting a child’s attention from the feared stimulus — and may be more effective than other distraction techniques.

But there’s no single best approach to easing fear, Caruso says. “It’s important to use tailored interventions. Children with mild worries may be calmed by listening to music, while others may be helped by virtual-reality techniques.”

Talk therapy can be helpful if anxiety persists or grows. Some children won’t outgrow their fears without such support, doctors find.

“Therapy doesn’t have to last forever,” Albani adds, “and brief cognitive-behavioral treatment or exposure therapy has been shown to help.”

Whatever strategy parents or other caregivers choose, acknowledging the child’s fear is the important first step, therapists say. Just like adults, kids feel validated when we acknowledge their worry, find them help and then let them know that everything is going to be OK.

And kids who learn to feel safe with their doctors early on are more likely to trust them with serious health concerns as they get older.

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