Walgreens’ Priority Was Filling Drug Orders Fast, Judge Told

A former Walgreens pharmacist felt pressured to “fill, fill, fill” prescriptions while working at a pace that made her fear making fatal errors, a California federal judge heard in recorded testimony Thursday in a multibillion-dollar bellwether trial over claims Walgreens and others illegally fueled San Francisco’s opioid epidemic.

The city of San Francisco has accused Walgreens, along with drugmakers Teva and Allergan and drug distributor Anda, of creating a public nuisance by marketing opioids with misleading messages about their safety and failing to prevent the ensuing flood of painkillers from being diverted for improper uses.

Thursday marked the second day of the bench trial in which the testimony focused on San Francisco’s case against the pharmacy chain. It included the recorded deposition of Rebecca Gayle, who worked at a San Francisco Walgreens as a staff pharmacist from 2012 to 2016, also holding the role of assistant store manager from 2014 to 2016.

“The most challenging part of working at Walgreens was I constantly felt there was the pressure to fill, fill, fill, and that was what the company cared about most,” Gayle said. “That’s the message I got.”

The demand to fill prescriptions quickly made it difficult for her to investigate suspicious prescriptions or talk to patients about their medications.

“I constantly got feedback to go faster, shave down on the things that were most important to me as a pharmacist like counseling patients,” Gayle said, later adding, “I ran into situations where I was afraid I made a lot of mistakes that could result in severe patient … harm or even death, depending on medication and the type of error.”

During Gayle’s cross-examination, a lawyer for Walgreens asked her if she believed she and her colleagues were doing their best on behalf of their patients and to make sure they prevented diversion.

“I feel like we, as pharmacists, could have had many more tools, and support from a staffing and time perspective, to do more due diligence to prevent diversion,” Gayle said. “We were doing our best, but it was limited given the volume of prescriptions we were filling and the pace at which we were expected to fill.”

Gayle said she would sometimes search doctors’ names on the internet if she felt something was fishy about them, as well as leave notes for her colleagues to warn them about doctors who appeared to be issuing excessive opioid orders.

If there was a strong red flag, Gayle said she and her colleagues would sometimes refuse to fill a prescription.

Brian Swanson of Bartlit Beck Herman Palenchar & Scott LLP, an attorney for Walgreen’s, asked Gayle if she was ever punished for refusing an order, and she said no.

Among doctors who had “fishy” prescribing practices was Collin Leong, Gayle said. He ultimately lost his license in 2013 and pled guilty to selling opioid prescriptions to homeless people with no medical justification, but not before Walgreens filled thousands of his prescriptions, according to a document the city filed with the court. 

An attorney for San Francisco showed Gayle a news article that said the homeless people would be given cash for the pills from a third party. Leong charged $80 to $150 for a prescription, taking in about $400,000, according to the news report.

“Did your district managers ever ask you to identify suspicious prescribers so they could warn others?” the attorney asked. Gayle said no.

Another former San Francisco Walgreens employee, Victor Lo, also testified that the store he worked at was inadequately staffed, making it difficult to do his job carefully.

“We always felt like we were behind, we always felt, at least I felt, I could potentially dispense something incorrectly,” Lo said.

Lo, however, testified that when he told his supervisor that he felt the pharmacy was dispensing a lot of narcotics from doctors who appeared to be “too free” in writing prescriptions, he was told the pharmacists couldn’t say no.

“We couldn’t categorically say flat out we’re not filling these prescriptions from a licensed prescriber. Those prescribers could sue Walgreens,” Lo said he was told.

In addition to Lo, live testimony was given Thursday from Carmen Catizone, who said Walgreens did not meet the standard of care legally required of pharmacies. Among concerns, from 2003 to 2012, Walgreens had a policy passed on to pharmacists to merely call the doctor who issued a questionable prescription as opposed to doing any other due diligence.

“This is especially true when the prescriber may be assisting the patient to inappropriately use controlled substances,” Catizone said.

In 2013, Walgreens introduced a checklist for pharmacists to use when dispensing some drugs, but it didn’t cover some commonly diverted opioids. Until 2020 the checklists were maintained only in hard copy at each pharmacy, and not electronically, so they could be shared with other stores, Catizone said.

During cross-examination, Swanson took aim at the list of “red flags” or warning signs that suggest opioid abuse or diversion that Catizone said pharmacists are required to be on the lookout for.

“You don’t cite any federal or state statute that discloses each of these specific red flags you identify, do you?” Swanson asked, later noting that they also don’t appear in the Controlled Substances Act.

Swanson also posed several hypothetical situations to Catizone that would result in a legitimate prescription being flagged. For example, if a patient obtained multiple opioid prescriptions from different prescribers.

“That would flag a patient who broke a leg and then gets an opioid script from the ER and then gets a second prescription from the orthopedist who treats them,” Swanson noted.

Walgreens’ lawyer also said pill volume wasn’t necessarily a red flag, for example, if a doctor was prescribing for an oncology patient or for pain management.

Catizone’s time on the stand was about 30 minutes, in keeping with Judge Breyer’s orders and a tight trial timetable, limiting direct witness examinations to written declarations with only a short live introductory summary.

Catizone, who served as the executive director and CEO of the National Association of Boards of Pharmacy from 1988 to 2020, also submitted a 35-page declaration to the court.

The Bay Area litigation is the first to rope together defendants across the pharmaceutical supply chain, from manufacturing to distribution and pharmacy dispensing.

San Francisco is represented by its city attorney’s office, Lieff Cabraser Heimann & Bernstein LLP, Robbins Geller Rudman & Dowd LLP, Andrus Anderson LLP, Weitz & Luxenberg PC, Simmons Hanly Conroy LLC and Levin Papantonio Rafferty.

Allergan and its affiliates are represented by Kirkland & Ellis LLP.

Teva and its affiliates are represented by Morgan Lewis & Bockius LLP.

Anda is represented by Foley & Lardner LLP.

Walgreens is represented by Bartlit Beck LLP and Gibson Dunn & Crutcher LLP.

The case is City and County of San Francisco et al. v. Purdue Pharma LP et al., case number 3:18-cv-07591, in the U.S. District Court for the Northern District of California. The MDL is In re: National Prescription Opiate Litigation, case number 1:17-md-02804, in the U.S. District Court for the Northern District of Ohio.

Filed under: General Problems