A Court Rejected the Disease Theory of Opioid Addiction. Will We Listen?

https://filtermag.org/court-opioid-addiction-disease/

The idea that opioid painkillers are inevitably addictive was put on trial and refuted. But this modern disease theory seemingly can’t be extinguished as long as it is granted “scientific” credibility by prominent experts and unquestioned acceptance by the media.

A 2016 book by Stanford addiction expert Dr. Anna Lembke—Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop—presented the hard-core, sinister case against drug companies. It’s a case firmly rooted in her view of opioid addiction as an irresistible, irreversible disease.

Meanwhile, the recent, high-profile Hulu series Dopesick is based on the 2018 bestseller by Beth Macy, a journalist who investigated the drug crisis in Appalachia. Macy’s book—Dopesick: Dealers, Doctors and the Drug Company that Addicted America—tells essentially the same story as Lembke’s. The company in question is (or rather, was) Purdue, run by the Sackler family.

The book and series maintain that Purdue/the Sacklers lied that OxyContin was rarely addictive. Instead, people frequently became hooked, and died, because addictiveness is an inherent property of opioids.

Hulu’s Dopesick aims for a feeling of authenticity by, for example, portraying a doctor who had been addicted to OxyContin.

Opponents of the disease model certainly don’t deny that many people become addicted to opioids and other drugs, as well as to powerful non-drug behaviors and experiences. Addiction is fundamental to human experience.

But pointing out the genuine addictive experiences of individuals like Dopesick’s doctor doesn’t shed light on the likelihood of becoming addicted to opioids.

Indeed, we know that likelihood is quite low.

Earlier this month, a court painstakingly ascertained just that, along with dispelling a litany of headline-grabbing claims about opioids 

A Court Rejects Lembke’s Arguments

Unlike Macy and Dopesick’s other producers, Lembke is highly credentialed—a psychiatrist, director of the addiction medicine clinic at Stanford University, and a TED speaker. She is thus deemed qualified to offer expert testimony in court.

On November 1, Judge Peter J. Wilson, in Orange County’s California Superior Court, issued a ruling in a case brought by four California jurisdictions against numerous opioid manufacturers over their alleged liability for causing addiction and many resulting deaths.

His ruling: “There is simply no evidence to show that the rise in prescriptions was not the result of the medically appropriate provision of pain medications to patients in need.”

The court rejected the plaintiffs’ claims, which were based primarily on Lembke’s testimony, finding her and the suing jurisdictions to be plainly wrong in four ways: overstating the incidence of prescription opioid addiction; ignoring the medical benefits of opioid pain relief; generalizing inappropriately from drug death “hot spots” to less severely affected jurisdictions; and failing to show that prescribing practices caused the crisis of opioid-related deaths.

Below are several illustrative quotes taken from an interview with drug manufacturers’ attorneys John Heuston and Moez Kaba, together with excerpts from the judge’s decision.

Hueston: “[The key factor] was Stanford professor Lembke. Dr. Lembke was presented as the lead voice by the plaintiffs for their case trying to establish [drug company] misstatements that drove the crisis in California.”

Kaba: “It’s an extraordinarily methodical order. He [the judge] goes through alleged statement after alleged statement and reaches the findings that these are not false statements …”

“The studies relied upon by Dr. Lembke for that conclusion are inadequate to support it.”

The judge, who regularly stopped the trial to hold detailed discussions about evidence, noted in his ruling that Lembke “testified that one in four patients prescribed opioids would become addicted.”

But, he continued, “as Defendants point out, the studies relied upon by Dr. Lembke for that conclusion are inadequate to support it … the more reliable data would suggest less than 5 percent, rather than 25 percent.” And even with that much lower figure, “addiction based solely on the patient having been prescribed opioids does not occur in ‘most of these patients.’”

Kaba: “One of the things that Dr. Lembke claimed, for example, was that it was false or misleading to suggest that opioids can improve the function of people who take them. And we had her admit very clearly, very plainly, that not just the FDA but the state of California itself in its own laws acknowledges that opioid medications when properly prescribed do, in fact, improve function.”

Defense attorneys were also at pains to contextualize the California jurisdictions’ claims. That is, opioid addiction and death rates are highly dependent on specific locales and social settings.

Defense attorney Hueston: “We certainly wanted to make sure that a case about the opioid epidemic in California actually related to California. And what we wanted to do was to anticipate and blunt the attack from plaintiffs that California is like Appalachia and Tennessee, or some of the other notorious hot spots.”

Kaba: “There’s another part of his order where he says that there’s no causation, which was another big part of our case. In the examination that [Heuston] did of our economist, we proved that there is no causation …”

Proving causation requires linking more prescriptions to greater addiction and death rates. In fact, while there has been a steady decline in painkiller prescriptions, by nearly half, from 2012 to 2020, drug deaths continued to achieve record levels over that period, more than doubling between 2015 and 2020 alone. Causality—if anything—seemingly flows in the opposite direction. That is, restricting painkiller prescriptions leads to negative outcomes.

An Assault on Chronic Pain Patients

The trial additionally highlighted patients’ right to pain relief, and how the disease theory of addiction attacks this right.

Organizations representing pain doctors have strongly objected to draconian limitations imposed on prescribing. The American Medical Association itself has passed “resolutions against the rash of laws and mandatory policies that limit or prevent patient access to opioid painkillers.” Beleaguered pain patients have organized themselves into a grassroots movement.

Heuston: “It was critical to our strategy to ensure that the voices that are in support of proper pain management were heard, that pain management doctors who could help describe the life crises of people who simply have inadequate treatment of pain … the judge’s opinion sets forth not only the understanding of that balance by the FDA and the federal government but how that is enshrined specifically in California in, for instance, the Patients’ Bill of Rights.”

Stanford Medical School and its hospitals, incidentally, subscribe to these rights, including that to opioid medication.

Little wonder that this month, a group representing people with arthritis and rheumatic disease, whose leadership had invited Lembke to present to it, rescinded its invitation: “We understand how some of Dr. Lembke’s previous work and comments can be problematic. Thank you for taking the time and energy to show us articles, interviews, and quotes from Dr. Lembke that are not in keeping with our mission at CreakyJoints.”

Drawing the Wrong Conclusions From Vietnam

The 2020 Netflix series The Pharmacist jumped from a drug-related murder in New Orleans to portray an overwhelming national epidemic of prescription-opioid overdoses due to addiction. This view is put forward in spite of the dominant roles in today’s unprecedented drug-deaths crisis of drug-mixing, of an illicit supply adulterated with fentanyl and its analogues, and of the policies that lead to these conditions. (Due to this toxic combination of factors, it is actually a misnomer to label the deaths simply as “overdoses.”)

Dr. Lembke was interviewed in the Netflix series. “This country has seen two prior opioid epidemics,” she said, citing the Civil War and “when soldiers were coming back from the Vietnam War.”

Most soldiers who used heroin didn’t become addicted, and the overwhelming majority of those who did quickly recovered stateside, without treatment.

But the Vietnam addiction story actually demolishes Lembke’s opioid disease model. As Zach Rhoads and I described in Filter, “Vietnam Vets Proved that Addiction is a Product of Life Circumstances.”

Most soldiers who used heroin didn’t become addicted, and the overwhelming majority of those who did (over 90 percent) quickly recovered stateside, without treatment. The small group whose addictions persisted were identified by their adverse social situations before and after the war.

In 2021, 50 years after Lee Robins’s iconic Vietnam research, science journalist Lauren Aguirre revisited “Lessons learned—and lost—from a Vietnam-era addiction study … It’s too bad this research has been largely forgotten because its lessons can be useful today.”

As Aguirre notes, “many people recover on their own from drug addictions … most of them did not receive formal treatment.”  Furthermore, “exposure to opioids doesn’t inevitably lead to a substance use disorder. Some people can use opioids occasionally without becoming addicted [this included veterans who had been addicted in Vietnam]. In fact, a recent analysis found that only about 3 percent of the tens of millions of people prescribed opioids become addicted.”

In this context, Netflix viewers were led to think that the Vietnam narrative supports Lembke’s (and Dopesick’s) underlying assumption of the inescapability of addiction. But their perspective—which dominates the popular and political discourse—is actually the reverse of the meaning we should have taken from the Vietnam opioid experience.

Media Boosting of the Disease Theory

Media of all kinds and all political stripes are typically stalwart presenters of the Dopesick/Lembke demonization of opioid painkillers. Joe Rogan (who interviewed Lembke*), PBS’s Christine Amanpour (who interviewed Macy), and MSNBC commentators (several of whom interviewed Dopesick producer Danny Strong and showed clips from the series) are just a few examples of the worshipful exposure media give to inaccurate suppositions about opioids.

Hulu promoted a clip from Dopesick in which a tearful Appalachian doctor says that most of his patients became addicted. MSNBC’s Joe Scarborough and Nicolle Wallace, to name two, eagerly endorsed this preposterous claim.

It is our obligation to firmly and finally reject the demonization of drugs—including portraying addiction as the inexorable, irreversible, unavoidable consequence of drug use.

Most media’s ignorance of drug issues has long been a given. More exasperating is when people who support drug policy reform implicitly endorse the disease theory. I recall one event in 2017, at which figures from New York government, public health and several harm reduction organizations celebrated successful efforts to reduce painkiller prescribing since 2012—while simultaneously depicting continually rising drug-related deaths over the same period.

It is our obligation instead to firmly and finally reject the demonization of drugs—including portraying addiction as the inexorable, irreversible, unavoidable consequence of opioid and other drug use.

Many harm reduction and reform advocates rightly focus on the critical role of the social, psychological and economic circumstances faced by people who experience drug-related harms. They understand that drug use is not an infection. It is both a normal behavior and a human response to distress. And they see drug use as a human right, and drug users as a constitutionally protected group.

We will never contain our epidemic of drug deaths until these anti-drug war, anti-disease realizations are more widely shared.

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A BRIEF MESSAGE FROM DESANTISBURG: WAOK JUANDOLYN STOKES: GUEST ISSUE WARNING ABOUT THE RECENT RESURGENCE OF COVID IN AMERICA

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WAOK “ON-POINT,” WITH JUANDOLYN STOKES, PRESENTS NURSING’s DIRTY LITTLE SECRET !!! (KILLING YOU AND YOUR COMMUNITY) AND THE PURGING OF BLACK NURSES FROM HOSPITALS IN AMERICA

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HELEN BOREL, PH.D., NABARUN DESGUPTA, PH.D, RICHARD LAWHERN, PH.D, MICHAEL SCHACTMAN PH.D. CPE., et. al., vs. NEW YORK ASSISTANT ATTORNEY GERNERAL DAVID ABRAMS, AG’s OFFICE FOR THE STATE OF NEW YORK, “PRESCRIPTION OPIOID CRISIS IS A MAGNIFICENT HOAX BASED ON NEO-EUGENICS”

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 vs.

RON CHAPMAN OF CHAPMAN LAW FIRM, DEFEATS DEA IN COLUMBUS, GA CASE OF U. S vs. DR. THOMAS SACHY, MD A NEURO PSYCHIATRIST

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Innocent Doctor In Federal Prison Seeking Help

https://www.gofundme.com/f/innocent-doctor-in-federal-prison-seeking-help

https://givesendgo.com/RandFamily

Welcome to the informational page on Robert Rand MD. Dr. Rand is in a Federal Prison in Los Angeles CA for the act of prescribing pain medications to patients of his that he truly believed needed these medications. Dr. Rand is a loving husband and father first and a doctor second. Dr. Rand’s wife is battling metastatic cancer while he fights for justice in Federal Prison after being railroaded into prison in a court presided over by a judge who had multiple serious conflicts of interest. Dr. Rand pled guilty to the charges against him in a court that he later found out was a court IN WHICH HE WAS DENIED DUE PROCESS OF LAW FROM THE VERY START OF THE PROCEEDINGS AGAINST HIM. Just as important, on July 22, 2022 The Supreme Court (SCOTUS) ruled 9-0 that the government must prove criminal intent when making cases against doctors. The case for reference is called the RUAN AND KAHN CASE. In this case lawyers for Dr. Ruan and Dr. Shakeel Kahn (now a close friend of Rand) argued that doctors had a right to prescribe pain medication and that many compassionate doctors do so without being criminally minded. This landmark case literally brought back into the law and the court the concept of mens rea or criminal intent into cases like Rand’s and many other cases and types of legal cases. This is after thousands of doctors like Rand had had their lives and careers shattered and destroyed. Rand has been locked up since 4/29/2016, which is at the time of writing is well over SEVEN FULL YEARS. Dr. Rand was a highly respected physician in Reno NV. Before going too much further we will provide a little background on Dr. Rand. Dr. Rand is in need of financial assistance for legal fees and for living and medical expenses for his wife who is bravely battling cancer while raising their daughter who is now eight years old. Dr. Rand was born and raised in NY City (Brooklyn) and later Northern NJ (Morristown NJ). His family always emphasized education as a value of paramount importance as is true with many if not most Jewish families. Rand had an uncle who he admired quite a bit. His uncle was a very prominent cancer specialist and scientist. Additionally Rand of course admired both his mother and his father, both highly educated. Rand’s father, a man who came here to the United States as a boy, not knowing word of English having escaped almost certain death from the Nazis Here in the US he became a lawyer. Dr. Rand always jokes that he was told that he could be anything he wanted to be when he grows up as long as he chooses to be a doctor or a lawyer. Dr. Rand chose somewhat of an alternate route in life and in college (Boston University) where he initially studied Anthropology and earned a BA. This prompted him to travel to East Africa, specifically to Kenya shortly after graduating with his degree in Anthropology. Dr. Rand ( Rand) had an epiphany on his first day in Africa, in Nairobi Kenya after seeing people living with medical conditions that the average American will never see. For Rand it was like “going back into the Bible”. There were men, women, and children with every affliction known to man, right there in open view. People that were suffering from all sorts of exotic tropical ailments and even Leprosy, seen on every street corner. The pain and suffering were immediately overwhelming to Rand, then about 23 years old. Robert Rand decided right then and there that he would some day “return to school to become a doctor”. He would devote his life to being a deeply compassionate doctor and care for the sick and infirm. After returning from Africa Rand initially become an Emergency Medical Technician and worked in various jobs related to being a first responder for several years. Later Rand returned to college to do the “premed” curriculum and then medical school. Rand went to medical school first in Mexico and then for two years on a Caribbean Island called Dominica. He completed his 3rd & 4th years of medical school in California but still noticed that there was a real issue with how doctors treated or in reality did not treat pain. This was true in the undeveloped Island of Dominica but also true right here in in the USA. In medical school both here in the US and overseas he noticed that there was a reoccurring theme with what he considered to be under-treated pain, both acute pain and chronic pain. This series of observations was reinforced when his mother was diagnosed with cancer and he noted that the doctors were to a large degree ignoring the pain that she was suffering from. By this point Rand was half way through medical school and knew enough to ensure that his own mother did not suffer. Her doctors considered him somewhat of a pest but she did not suffer because he was vigilant at her bedside. The theme of under-treated pain is something that he recognized throughout his entire medical education and into his career being a doctor who both ran a clinic and worked in several hospitals which he did right up until his arrest in 2016. As a matter of fact one of the most notable things was that the nurses at the hospital where Rand worked would literally wait until he was on call and then call to request various orders and medications including pain medications for their patients as the nurses often felt that their patients needed these medications including “pain meds”. Indeed the pain crisis is not just in the outpatient setting but it effects patients in every hospital in the USA. Dr. Rand ran a practice in Reno NV, which had become a large practice in part due to referrals from other doctors in the community. As mentioned above Dr. Rand also had “admitting privileges” in four local hospitals in the Reno/Sparks NV area and in actuality had been working consistently at one of the hospitals for 5 years prior to his arrest, working about 200 shifts per year in addition to running his busy clinic. Since “the FEDS” (and the states) have “cracked down on pain doctors” overdose rates have gone up, not down. This is especially true amongst VETERANS often injured in war. Veterans suicide rates have been shown to go substantially up when their pain medications were taken away. Rand took in many Veterans who had been on pain medications for years or decades and were made to quit cold turkey due to draconian governmental policies. In addition many people have finally decided that they want LESS GOVERNMENT INTERVENTION into their lives when medical decisions are on the table. On a another note as mentioned above, Rand’s beloved wife is battling metastatic breast cancer and now has a significant case of anemia. All of this while raising their beautiful daughter with only limited help from her husband who can only help so much from inside prison. A few facts to consider: Pain can and does effect all types of people from all walks of life. (PAIN DOES NOT PLAY POLITICS !) RAND TREATED EVERYONE WITH COMPASSION. The overdose rates have sky rocketed since the FEDS started to incarcerate doctors. Suicide rates of pain patients including Veterans have also sky rocketed since the FEDS went to war against pain doctors and pain patients. Rand’s legal fees have already gone above an estimate of about 750,000. That is over 3/4 of a million dollars. There were very serious conflicts of interest that Rand discovered after the proceedings were finished. When Rand via his lawyer brought that up the Judge initially punished (sanctioned) Rand’s lawyer. When it comes to conflicts of interest Rand’s same judge has written a specific legal opinion that completely contradicts her statements in Rand’s case. The Department of Justice and Court system have been weaponized against Rand and he was denied due process of law. Rand himself has a history of fracturing his own spine in FOUR places and also has developed complex regional pain syndrome in his right foot. He knows what it is like to be ignored and disbelieved by doctors. RAND’S FATHER ESCAPED FROM THE NAZIS TO COME HERE BUT GENUINELY KNEW THAT AMERICA HAD TURNED INTO A POLICE STATE AND STATED THAT PLAINLY PRIOR TO HIS DEATH IN 2020. Rand is well aware of the financial burden on chronic pain patients and the state of the economy and is grateful for any donations toward his case and this important cause. Finishing off with a couple of poignant quotes: “Pain is a more terrible Lord of man than even death itself.” Albert Schweitzer, a famous humanitarian physician, missionary. Dr. Schweitzer went to prison camp for a bit himself. First they came for the communists and I did not speak out because I was not a communist. Then they came of the Socialists and Trade Unionists but I did not speak out because I was neither. Then they came for the Jews but I did not speak out because I was not a Jew. And when they came for me there was no one left to speak out. Martin Niemoller German WWI Submariner who despite being a WWI Hero spoke out against the Nazis and himself was put into a concentration camp for doing so. Thank you for your time in reading this and again any donations and or even prayers are appreciated.

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Some may think that this could really open a can of worms, but could be a can of “dead worms”. Most law firms – particularly the ones who will take a case on a contingency basis – look for some “deep pockets” to go after. I may be wrong, but I suspect that when we see a LARGE SETTLEMENT from some bureaucracy… those $$$ may come from some insurance policies. However, states that go down this path, the premiums for those policies may GO THRU THE ROOF.

New Mexico ends qualified immunity

https://thehill.com/homenews/state-watch/547001-new-mexico-ends-qualified-immunity/

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As more children die from fentanyl, some prosecutors are charging their parents with murder

https://apnews.com/article/children-fentanyl-deaths-parents-charged-california-4767deae62a1ae1d9fa17a3edcc73f73

SANTA ROSA, Calif. (AP) — Madison Bernard climbed into bed before dawn with her toddler, Charlotte, who was asleep next to a nightstand strewn with straws, burned tinfoil and a white powder.

Hours later, the mother woke and found her daughter struggling to breathe, according to investigators who described the scene in court documents.

After being rushed in an ambulance to a hospital, the 15-month-old girl died from a fentanyl overdose. Her mother and father, whom authorities said brought the drugs into their California home, were charged with murder and are awaiting trial.

The couple has pleaded not guilty but are part of a growing number of parents across the U.S. being charged amid an escalating opioid crisis that has claimed an increasing number of children as collateral victims.

Some 20 states have so-called “drug-induced homicide” laws, which allow prosecutors to press murder or manslaughter charges against anyone who supplies or exposes a person to drugs causing a fatal overdose. The laws are intended to target drug dealers

In California, where the Legislature has failed to pass such laws, prosecutors in at least three counties are turning to drunk driving laws to charge parents whose children die from fentanyl overdose. It’s a unique approach that will soon be tested in court as the cases head to trial.

Supporters of the ramped-up enforcement say that by now those who use the synthetic opioid know the lethality of the drug and, like drunk drivers, they should know the consequences of exposing their children to their actions.

Critics say the parents didn’t intend to kill their children but instead made poor choices because of their addictions and are being further punished instead of being offered help.

The debate comes as the country battles with how to effectively diminish the use of the highly accessible and extremely deadly drug.

Authorities believe some of the children died after touching something with the powdery substance and then touching their eyes or mouth. In one case, the drug may have been on the hands of a parent who prepared the baby’s bottle. The drug is not absorbed into the skin but experts say it can be lethal if as little as 2 milligrams, about the weight of a mosquito, enters the body.

“These are tragic cases because drug addiction has destroyed a precious life and the parents face the consequences of their reckless actions,” said Charlie Smith, the top prosecutor in Frederick County, Maryland, and president of the National District Attorneys Association.

Parents also can face charges if young children become seriously ill or die from crack, heroin and cocaine, but such cases are rare because a sizeable amount must be ingested, Smith said.

“This is really a first in the history of our country because we have a drug on the streets that can potentially kill you instantly with a minor amount of product,” Smith said.

Prosecutors have a difficult decision to make when determining whether to charge parents, but Smith said the goal is to deter others from doing the same.

He prosecuted a case in which parents in Maryland were convicted of involuntary manslaughter in the 2020 death of their 2-month-old son. The Mount Airy couple had mixed fentanyl in the same bathroom where they prepared bottles for their infant.

Jeremy Whitney Frazier and Heather Marie Frazier were each sentenced in December to five years in prison and five years of supervised probation.

The National District Attorneys Association doesn’t track how many parents have been charged for exposing their children to fentanyl, but news reports and interviews with prosecutors show such cases have been on the rise since the onset of the pandemic.

Last month, a Maine woman pleaded guilty to manslaughter after her 14-month-old son’s fentanyl overdose. Investigators found fentanyl on a blanket and sheet where Ashley Malloy’s son Karson had been sleeping.

States such as Maryland that don’t have “drug-induced homicide” laws often charge parents with manslaughter, Smith said.

In California, prosecutors have turned to a drunk driving law.

Prosecutors in Riverside, Sonoma and Stanislaus counties have charged parents with murder based on the “Watson advisement,” a formal statement signed by anyone convicted of a DUI charge who says they understand driving under the influence can injure or kill people. The statement can be used against them if they cause another fatal, DUI-related crash.

“I’ve been a prosecutor 25 years now and I can’t recall any other drug that has led to this much destruction and death,” Riverside County Deputy District Attorney Daima Calhoun said.

Prosecutors say the parents, like drunk drivers, knew fentanyl can injure or kill people.

Among those awaiting a trial that will test the approach are Tehra Alexandra Waite and Collin Pascal Kittrell, both of Riverside. The boyfriend and girlfriend were charged with murder after their toddler died of a fentanyl overdose in June 2020. They pleaded not guilty.

Investigators said their 14-month-old daughter, Allison, likely touched her mouth or eyes after coming in contact with the drug, which was found on several things in their apartment, including the couch.

Detectives testified that when Waite found her daughter unresponsive she rushed to a pharmacy to buy naloxone, a drug used to reverse an opioid overdose. The couple did not call 911 until hours later when Allison started having trouble breathing.

The girl’s paternal grandmother also said in court documents that Waite used drugs while she was pregnant.

The Associated Press sought comment from multiple attorneys who have represented Waite and none responded. Her father declined to comment.

Kittrell’s attorney, Graham Donath, said Allison’s father did not intend for his child to die and the charge should be one of child neglect, not murder. But prosecutors don’t like to go that route because the maximum sentence for the offense is 12 years.

In Sonoma County, where Charlotte slept with her mom in a messy apartment in Santa Rosa, first responders testified at a preliminary hearing that they found fentanyl in powder form on a nightstand next to the bed.

Ryan Hughes, a Santa Rosa Police Department narcotics detective, told the court they also found text messages showing the couple was concerned about losing their daughter because of their drug use, the Santa Rosa Press Democrat reported.

A judge is expected to set a trial date at a Sept. 11 hearing for Charlotte’s mother, Bernard, who woke up to find her daughter struggling to breathe, and her father, Evan Frostick.

Defense attorneys for Bernard and Frostick and Frostick’s parents all declined to comment when contacted by the AP. Bernard’s stepmother did not respond to phone messages seeking comment.

“They need to be held accountable under the law because they allowed harm to come to their children and they let their drug use and addiction outweigh taking care of their children and keeping their children safe,” Sonoma County District Attorney Carla Rodriguez said.

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California pharmacies are making millions of mistakes. They’re fighting to keep that secret

https://www.latimes.com/business/story/2023-09-05/california-pharmacies-prescription-errors-cvs-walgreens

Sharri Shaw walked out of the CVS on Vermont Avenue in South Los Angeles in 2019 believing she had a prescription for the pain reliever acetaminophen.

Instead the bottle held a medicine to treat high blood pressure, a problem she did not have.

Shaw began taking the pills, not learning of the mistake until six days later when a CVS employee arrived at her home, according to a lawsuit she filed last year. The employee told her not to take the tablets, the lawsuit said, before leaving the correct prescription at her door. The mistake, she said, left her stunned.

Shaw’s experience is far from an isolated event. California pharmacies make an estimated 5 million errors every year, according to the state’s Board of Pharmacy.

Officials at the regulatory board say they can only estimate the number of errors because pharmacies are not required to report them.

Most of the mistakes that California officials have discovered, according to citations issued by the board and reviewed by The Times, occurred at chain pharmacies such as CVS and Walgreens, where a pharmacist may fill hundreds of prescriptions during a shift, while juggling other tasks such as giving vaccinations, calling doctors’ offices to confirm prescriptions and working the drive-through.

Christopher Adkins, a pharmacist who worked at CVS, and then at Vons pharmacies until March, said that management policies at the big chains have resulted in understaffed stores and overworked staff.

“At this point it’s completely unsafe,” he said.

Adkins now works at an independent pharmacy company in Los Angeles. He isn’t the only pharmacist worried that heavy workloads and distractions are leading to errors.

In a survey of California licensed pharmacists in 2021, 91% of those working at chain pharmacies said staffing wasn’t high enough to provide patients adequate care.

Although the board requires pharmacies to document errors internally, inform patients about mistakes in certain cases and learn how to prevent them from occurring again, only 62% of chain pharmacists said stores were following those rules, according to the survey.

Mistakes with deadly consequences

Medication errors can harm patients, sometimes seriously.

One patient took prednisone, a powerful steroid, for 89 days after a Walgreens pharmacist in Santa Clara confused the drug with Prilosec, the heartburn drug that had actually been prescribed, according to a citation issued in June 2022. Research has shown that prednisone can decrease bone density within weeks of starting the drug, increasing the risk of fractures.

In Inglewood, a pregnant patient suffered a fall after she was given two drugs prescribed to another customer by a pharmacist at the CVS on Market Street, according to an August 2021 citation.

At a Rite Aid in Bakersfield, a pharmacist typed the wrong instructions on a prescription for anastrozole, a hormonal treatment for breast cancer. The pharmacist told the patient to take half a tablet twice a day rather than twice a week as the doctor had prescribed. The patient took the drug according to the incorrect instructions for several days, according to a January 2023 citation, suffering “adverse effects.”

Some patients have continued to take and refill the prescriptions without knowing they received the wrong drug. A pharmacist in Adelanto at the CVS on Palmdale Road gave a patient another customer’s prescription for 50-milligram tablets of Zoloft, the antidepressant, according to a February citation. The person took the wrong drug for at least seven months, refilling the prescription three times.

The pharmacy board says it investigates any report of an error that it receives from consumers or others. If the investigation finds that regulations were violated, the board can issue citations and fines and possibly take away the pharmacist’s or pharmacy’s state license.

CVS and Walgreens declined to make executives available for interviews but sent statements saying that the errors were rare. Rite Aid did not respond to messages.

“Patient safety is our highest priority,” CVS said in its statement. “When we learn of a prescription error, the first priority of our pharmacy teams is caring for the patient, taking steps to correct the error, working with the patient and the prescriber.”

CVS said it does not comment on litigation.

Walgreens said it has “a multi-step prescription filling process with numerous safety checks to minimize the chance of human error.”

“When errors do occur, we also have a robust mandatory reporting system in place that allows us to quickly identify root causes and to implement process improvements to prevent future errors,” Walgreens said.

Vons said in a statement that the company makes sure pharmacies are appropriately staffed. “We also regularly review the workflow in our pharmacies to identify ways to streamline and automate non-patient facing tasks so that our pharmacy teams can dedicate more time to serving our customers,” the company said.

Some errors have been deadly. More than 10% of malpractice claims against pharmacists were for injuries that resulted in death, according to a 2019 report by two insurance providers.

The leading cause of death was from overdoses, in which patients were given dosage strengths that were too high or incorrect instructions that multiplied the amount of medicine the patient received.

As many as 9,000 Americans die each year from prescription errors, according to one study.

‘Virtual verification’

The chain pharmacies told The Times they are using technology to give pharmacists more time to keep patients safe.

Walgreens said, for example, it uses “micro-fulfillment,” in which prescriptions are filled by robots at regional centers.

One method of automation used by CVS is mentioned in at least seven citations by the pharmacy board since July 2022. The technique, called “virtual verification,” allows a pharmacist to sign off on a prescription without seeing what pills are put in the bottle.

Instead a lower-paid technician, hired to help the pharmacist, finds the drug to fill the prescription, counts the pills and then snaps a photo just before putting the tablets in the bottle and stapling the bag shut. The pharmacist approves the prescription based on the photo rather than actually observing the pills.

According to a June 2022 citation, one patient received a bottle of Valtrex, which treats viral infections, rather than the prescribed Keflex, which treats bacterial illnesses, from the CVS on Lankershim Boulevard in North Hollywood.

“Pharmacist verification based on the photograph … obstructs the pharmacist’s ability to verify the prescription,” the regulators wrote on the citation, which imposed a $5,000 fine.

Since those citations were issued for errors, the board agreed to withdraw the part of its findings related to virtual verification at five pharmacies after meeting with CVS executives, according to a letter the board sent to the company. The executives told board officials that they had improved the process, including by making it easier for pharmacists to see the pills in the photographs. The board said it “remains concerned” that relying on photos could increase errors, the letter said. CVS told the board it has not seen an increase.

The fight for more accountability

Rarely does the public learn of the mistakes. Not only does the state not require the reporting of errors, but the big pharmacy companies often ask consumers to sign agreements demanding that they take any dispute not to court but to private arbitration panels.

Patients typically agree to arbitration when they are asked to click a box to accept the company’s terms and conditions when they pick up a prescription.

“You agree that CVS and you each waive the right to trial by a jury,” states the CVS agreement.

To begin understanding the frequency of the mistakes, the pharmacy board sponsored a bill that would require pharmacies to report every error — not publicly but to a third party outside the government. The bill would also give the pharmacist responsible for the store the ability to increase staffing if they believe the workload has become too heavy to keep patients safe.

The legislation is opposed by the California Community Pharmacy Coalition, a lobbying group representing retail pharmacies, including the big chains. The coalition has told legislators that the pharmacy staffing requirements are too rigid and that it does not want the pharmacy board to have access to the error reports, among other objections with the bill. The coalition did not respond to a request for comment.

Language in the bill being debated in Sacramento states that the board would not get access to the reports — and neither would the public. Instead the reports would be kept confidential. The third-party group receiving the error reports would periodically provide information to the pharmacy board, including how many mistakes have been reported.

The pharmacy board said it hopes to use the information to learn more about what is causing the errors and what can be done to reduce them. The bill would allow the board to publish de-identified information compiled from the data in the reports.

The bill, AB 1286, authored by Assemblymember Matt Haney, a San Francisco Democrat, has passed the Assembly and is now before the state Senate.

“Shockingly, there’s no centralized reporting mechanism for medication errors,” Haney said in an interview. “There should be transparency, and the Board of Pharmacy should have the authority to respond to protect patients. That’s not happening right now.”

Two years ago, the state Legislature passed a bill that banned chain pharmacies from setting quotas for pharmacists on the numbers of prescriptions filled, vaccines given or other activities during a shift. The law’s goal was to make the chain pharmacies safer.

In the 2021 survey, taken before that bill passed, 73% of chain pharmacists said their employer monitored the number of prescriptions filled and 62% said the company monitored the average time it took them to fill a prescription.

Despite the new law, some chain pharmacies have continued to require pharmacists to meet quotas, according to citations issued by the board. Since January 2022, at least five pharmacies have been cited for asking pharmacists to meet quotas.

CVS set quotas and measured pharmacists on the number of vaccinations they gave each week, according to a March citation issued to the company’s pharmacy in Ripon, a town in the Central Valley. The citation included a $10,000 fine.

CVS declined to answer questions about the citation. It said it did not set quotas for pharmacists or pharmacy technicians.

A pharmacy board inspection at a Walgreens in Citrus Heights in August of last year found that the store had set quotas for pharmacists on the number of COVID-19 tests dispensed and vaccinations given.

The quota was “expressly encouraged by Walgreens corporate ownership,” the citation said. The pharmacy was fined $50,000, and an additional $5,000 for the inspectors’ finding that a pharmacist had dispensed a prescription of atenolol, a blood pressure medicine, without consulting with the customer about how to safely take it. That consultation is required by state law if the drug hasn’t been given to the patient previously.

Walgreens said it disagreed with the citation and was challenging it. “Walgreens does not utilize quotas for pharmacists or pharmacy technicians,” the company said, “and was in compliance with the new law before it went into effect.”

In a nationwide move last fall, Walgreens announced that it would no longer evaluate its pharmacy staff on any task-based metrics.

Adkins, the former chain pharmacist, said that when he began working at CVS pharmacies in the Bay Area in 2020, he accidentally gave a customer another patient’s prescription.

He said he was the only person in the pharmacy at the time.

“I was having to go back and forth between the register and filling prescriptions and answering the phones, and one patient came in to pick up a medication, which wasn’t ready because I was behind,” Adkins said. “So I had to go get it ready really quickly.”

He gave the customer her prescription and realized after she left that he had made a mistake.

Adkins said he quickly called the customer, finding she was still in the parking lot. Although the patient ultimately received the correct prescription, he said, she was angry at the dangerous mistake.

“It was my fault,” Adkins said. He said he believes it would not have happened if he’d had staff to help him.

“The public does not realize what’s going on behind the counter,” he said.

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