I find it interesting that in this article this statement – As for Walgreens, recent litigation revealed that the pharmacy used an “honor system” rather than conducting regular audits of pharmacists’ prescribing patterns

Pharmacists do not have prescriptive authority and has neither the training nor facilities to do an in-person exam, but make some sort of  the appropriateness of the prescription for the pt.

And it seems that they are working with some on data that was over a decade old. It is claimed that the USA gets 17 million new chronic painers every year. Is the trouble with proper treatment of chronic pain pts going to get worse or is the “powers to be” trying to use covert genocide to reduce the number of existing chronic painers we now have?

US Government Sues Pharmacy Chains CVS and Walgreens for Their Alleged Role in the Opioid Epidemic

https://www.doximity.com/collections/43b4c0fa-83e6-4c62-989d-f157d619bc81

In the span of 30 days, the US Department of Justice (DOJ) sued both CVS and Walgreens, along with dozens of their state subsidiaries. The country’s largest pharmacy chains—which collectively operate more than 17 000 storefronts—aided and abetted the opioid epidemic, the federal lawsuits—filed last December and this January, respectively—allege.

The civil lawsuits by the DOJ rest on the allegation that the pharmacy chains violated both the Controlled Substances Act (CSA) and the False Claims Act (FCA).

The CSA states that narcotics can only be used for “a useful and legitimate medical purpose.” By filling prescriptions that were invalid, the pharmacies “made choices that caused these millions of violations of federal law,” the DOJ alleged in the Walgreens lawsuit. The FCA, for its part, states that entities cannot knowingly present a “false or fraudulent claim” for government payment—either due to “deliberate ignorance” or “reckless disregard” of the claim’s falsehood. The DOJ alleged that by requesting reimbursement from Medicare and Medicaid for illegitimate prescriptions, the pharmacies broke the law. They unlawfully dispensed “massive quantities of opioids and other controlled substances to fuel its own profits at the expense of public health and safety,” the lawsuit against CVS stated.

To substantiate its claims, the government unsealed more than 800 pages associated with the civil complaints that included thousands of “false or fraudulent” prescriptions filed by the pharmacy giants between 2012 and 2024, including hundreds written by clinicians known to operate so-called “pill mills.”

In doing so, the pharmacies not only defrauded taxpayers under the FCA but also helped exacerbate the country’s ongoing fatal overdose crisis by routinely dispensing “extremely high doses and excessive quantities of potent opioids that fed dependence and addiction,” the DOJ alleged in its CVS complaint.

The assertion that pharmacies played a role in stoking the opioid epidemic is not new, according to Dorie Apollonio, PhD, MPP, a professor in the Department of Clinical Pharmacy at the University of California, San Francisco (UCSF).

Pharmacists have an independent legal responsibility under federal law to properly fill prescriptions for controlled substances, but rather than being seen as the critical “backstop of appropriateness of the prescription,” Apollonio said, people tend to think of pharmacists as being limited to “‘lick, stick, count, and pour.’” From the beginning, opioid manufacturers “were not ignorant of the role of pharmacists” in selling their products, she added, and “made a lot of effort to try to convince pharmacists to fill prescriptions they might not have formerly believed that they should.”

The opioid manufacturing industry adopted tactics including offering pharmacists financial incentives and bonuses for filling more and more prescriptions, Apollonio said. But there were also more insidious strategies, like sponsoring continuing medical education sessions for Walgreens’ pharmacists that were led by drug company liaisons. This achieved the dual goal of helping the pharmacist understand the supposed need for high dosage levels and securing exclusive product promotion rights, including “‘guaranteed’ stocking of future products at specific key stores,” according to an email exchange between corporate leaders at Walgreens and opioid manufacturer Purdue Pharma, which was cited in the study about improper opioid dispensing practices that Apollonio coauthored. (Purdue has separately paid out billions of dollars in settlements for its role in stoking the opioid epidemic, as have individual members of the Sackler family, who owned a controlling interest in Purdue.)

Academic scholars, such as Marie Chisholm-Burns, PharmD, PhD, MPH, and her former team at University of Tennessee’s Health Science Center College of Pharmacy, have previously pointed to pharmacists’ complicity with the pharmaceutical industry’s “widespread, aggressive marketing campaign advocating long-term use of opioids…which minimized the risks of addiction and overexaggerated benefits.”

Most notably, experts reference the American Pain Society’s 1995 guidelines for acute pain treatment, which encouraged physicians and pharmacists to provide “attentive analgesic care” to patients. The guidelines would later prompt the society’s campaign to treat pain as the “fifth vital sign.” By late 2000, toolkits like one authored by the Veterans Health Administration specifically identified pharmacists as “critical to the development of a reliable and comprehensive understanding of the patient’s pain and associated problems.”

The lawsuits against CVS and Walgreens are not the first for the pharmacy giants. In 2022, 2426 municipalities across all 50 states and 6 additional US territories reached a more than $4.2 billion settlement with CVS for its failure to properly monitor suspicious orders of opiates. Walgreens has made similar settlements, as has Walmart, which operates more than 5000 retail pharmacies.

In contrast to the federal lawsuits—which invoke federal legislation—the state complaints varied in accordance with differences in state legislation.

Many of the state lawsuits cited statutes aimed at preventing consumer fraud. For example, Rhode Island alleged that the pharmacies violated the state’s Deceptive Trade Practices Act by “deceiv[ing] and mislead[ing] prescribers into prescribing and consumers into seeking and taking medically unnecessary and…harmful quantities and strengths of opioids.” In Maryland, Walgreens violated the state’s Consumer Protection Act, for “falsely represent[ing] that the opioids it sold were safe and effective” and failing to undertake “adequate steps to ensure customer safety,” Attorney General Anthony Brown alleged.

Some complaints included additional charges, depending on the particular state law and applicability of additional legislation. For instance, the Rhode Island suit alleged that the pharmacies violated the state’s public nuisance law by “failing to provide effective controls and procedures to guard against diversion of opioids.” The Washington state suit also claimed that several pharmacies violated public nuisance law by contributing to the opiate crisis in a manner “unreasonable and harmful to the health of Washingtonians” that “interferes with the comfortable enjoyment of life.”

The settlements have had some positive impact, largely by obtaining funds for state efforts to address the opioid crisis. These public health initiatives include providing youth education about the risks of opioid abuse, purchasing and distributing naloxone for overdose prevention, and establishing residential detoxification centers, according to an opioid settlement spending tracker maintained by the National Academy for State Health Policy.

The settlement money has also contributed to building out infrastructure for public health surveillance related to opioid misuse. For example, according to the Federation of State Medical Boards, every state now maintains a prescription drug monitoring program (PDMP) designed to deter opioid abuse and diversion. However, as it stands, studies show that the breadth—and enforcement—of PDMPs varies considerably state-to-state in ways that can lead to unintended consequences, like inappropriately “dumping” patients who depend on long-term opioids for pain relief.

If the DOJ is successful in its lawsuits—what Peter Neronha, JD, attorney general of Rhode Island, calls an attempt to “get their pound of financial flesh”—the funds may serve to supplement these inconsistently effective efforts. Although Neronha said he was unsure how it could work, he suggested fashioning the settlements “in some way to reach Americans directly” as opposed to allowing that money to flow back to federal agencies without earmarking for specific or regional initiatives.

Scholars like Joshua Sharfstein, MD, and Sara Whaley, MPH, MSW, both at Johns Hopkins University’s Bloomberg School of Public Health, have raised other concerns related to ineffective use of opioid settlement money.

Often, funds are spent right away, “squandering the chance to invest in programs for the long-term,” or they are spent on ineffective or unproven programs, Sharfstein and a coauthor wrote in a 2020 article in JAMA. Similarly, they noted, authorities responsible for spending these funds frequently fail to develop systems that can evaluate on an ongoing basis whether the programs are actually working.

What the settlements do stand to provide is better public knowledge of pharmacies’ role in the crisis. A West Virginia lawsuit, for example, uncovered considerable flaws in CVS’s ability to effectively monitor suspicious orders: an algorithm purported to reduce human error in prescription surveillance was ultimately determined to render analyses that were “for the most part, irrelevant and pointless.”

As for Walgreens, recent litigation revealed that the pharmacy used an “honor system” rather than conducting regular audits of pharmacists’ prescribing patterns—even as there was a “general sense that Walgreens pharmacies may be lacking in some compliance areas.” The lawsuit further identified numerous examples in which patients died of overdoses shortly after filling their prescriptions at Walgreens—and whose autopsies noted intoxication with the very medications they’d been dispensed just a few days prior.

Depending on how federal lawyers choose to pursue the cases, a variety of documents—from emails to board minutes to memos—could further “shed light on what the business practices were” at US pharmacy giants, Neronha said. Those kinds of details could prompt new approaches to monitoring, regulation, enforcement, and future litigation. (The Opioid Industry Documents Archive, a collaboration between Johns Hopkins and UCSF, contains more than 22 million pages from 4 million internal corporate documents obtained in part through litigation.)

But transparency related to historic practices alongside a well-spent national financial settlement may not necessarily mean substantive, or durable, change in the opioid crisis when day-to-day operations of individual pharmacies are not standardized. For instance, research by Apollonio’s team suggests that such procedures as those surrounding “red flag” prescriptions vary immensely between stores, even when owned by the same parent chain.

Furthermore, states have had a limited ability to enact injunctions against harmful actions, beyond garnering financial payments for damages. Studies on other forms of litigation of large-scale public health concerns—including tobacco, asbestos, and lead paint—have likewise demonstrated that efforts to prohibit illegal and detrimental practices have historically taken a back seat to financial remuneration.

And, according to investigations by organizations like the Ohio Board of Pharmacy (OBP), the conditions that led to regularly filling problematic and dangerous prescriptions are deeply ingrained in large chain pharmacies like CVS and Walgreens.

In 2021, data published by the OBP found that 49% of more than 2900 CVS pharmacists across the state disagreed that they had “adequate time to complete [their] job in a safe and effective manner,” and 88% agreed that they “feel pressure” by their employer or supervisor to “meet standards or metrics that may interfere with safe patient care.” Insufficient staffing was also common at chain pharmacies and negatively affected patient care, according to nearly half of respondents.

“Company focus on metrics makes the current practice of pharmacy unsafe and results in high risk of errors,” one respondent wrote. “We are constantly expected to ‘do more’ with less.”

In February 2024, OBP took steps to address these patterns through a settlement with CVS that placed 8 of the pharmacy’s storefronts in the state on probation and, among other provisions, required the chain to address understaffing and reduce the use of quotas to incentivize pharmacist behavior.

Still, according to Cameron McNamee, OBP’s policy and communications director, these actions alone are not enough. The real question, he said, is whether the federal litigation can lead to widespread systematic changes at pharmacies, including changes that state agencies themselves lack the jurisdiction or authority to make.

“The pharmacists are the gatekeepers—they have the keys to the kingdom, and they’re that last stop for the patient,” McNamee said. “They have that obligation [to protect patients] under the law, but whether they follow it is a

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