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This summer, the Sackler family, founders and owners of Purdue Pharma, announced they would pay at least $3 billion of a proposed $12 billion settlement of more than 2000 cases filed by cities, states and local government for its part in the opioid epidemic.  The Sackler portion of the settlement money would be obtained by the family selling off Mundipharma, a separate global pharmaceutical company they own.

So this announcement may raise questions about the little known Mudipharma company reportedly owned by the Sacklers.  A story just published in the Guardian sheds some light on what the Sacklers might be up to with Mundipharma.

After decades of stringent narcotics laws, borne of debilitating opium epidemics of centuries past, India is a country ready to salve its pain. For-profit pain clinics are opening by the score across Mumbai, Kolkata, Bangalore and other cities in this nation of 1.3 billion people.

And American pharmaceutical companies – architects of the opioid crisis in the United States and avid hunters of new markets – stand at the ready to fuel that demand.

Most large Indian hospitals have added pain management as a specialty in recent years. At the insistence of the professional societies that accredit hospitals in India, nurses and doctors now are required to assess pain as a fifth vital sign, along with pulse, temperature, breathing and blood pressure.

The pharmaceutical industry has kept pace. Twenty years ago only a few pharmaceutical companies marketed pain medicines in India, Today, almost every company is having pain management as a separate division.  A salesman for Sun Pharma, India’s largest drugmaker by sales, echoed the point during an interview in Chandigarh, the capital of Punjab and Haryana.

For Indian cancer patients who once writhed in agony, there are fentanyl patches from a subsidiary of Johnson & Johnson.  For the country’s vast army of middle-class office workers wracked with back and neck pain, there is buprenorphine from Mundipharma, a network of companies controlled by the Sackler family, the owners of Connecticut-based Purdue Pharma.

And for the hundreds of millions of aging Indians with aching joints and knees, there are shots of tramadol from Abbott Laboratories.

Palliative care advocates, who recount stories of patients enduring excruciating cancer pain or dying in agony, have persuaded reluctant government officials to allow high-powered opioid painkillers into doctors’ offices and on to chemists’ shelves.

But what began as a populist movement to bring inexpensive, Indian-made morphine to the ill has given rise to a pain management industry that promises countless new customers to American pharmaceutical companies facing a government crackdown and mounting lawsuits back home.

The lure of a pain-free life is a revelation in a country where incomes are rising for many city dwellers and 300 million to 400 million people are approaching the middle-class. Newly-minted pain doctors promise aspiring Indians that life has more to offer in a body free from pain.

As major pharmaceutical companies look to capitalize on the opportunity, the playbook unfolding in India seems familiar. Earnest advocates share heartbreaking stories of suffering patients; physicians and pharmaceutical companies champion pain relief for cancer patients and persuade regulators to grant greater access to powerful opioids; well-meaning pain doctors open clinics; shady pain clinics follow; and a spigot of prescription opioids opens – first addressing legitimate medical uses but soon spilling into the streets and onto the black market.

A looming deluge of addictive painkillers terrifies some Indian medical professionals, who are keenly aware that despite government regulations most drugs are available for petty cash at local chemist shops.