Terry Maguire tries to establish where the blame lies for America’s devastating opioid epidemic

With focus on Covid-19, the US opioid pandemic has largely been ignored here, yet continues to destroy lives, devastate families and fracture communities and it worsened rather than lessened as Covid-19 ravaged the US. The US Centres for Disease Control published provisional data recently, showing that 2020 was a record year for drug overdose deaths with 93,331, up 29 per cent from a year earlier.

Some 500,000 deaths between 1999 and 2019 need to be explained, so cities, states, counties and finally federal authorities are taking legal action against those they view as the perpetrators, and it’s not the Mexican drug cartels; it’s the white-collar players of corporate America, the very essence of the capitalist model. In the dock
are Big Pharma, who manufactured and marketed the drugs; their advisers, who provided the strategy; the wholesalers who distributed; and the national pharmacy networks, who supplied.

ups on learning that legal action is being taken follows a similar pattern. Firstly, they claim the opioid crisis is nothing to do with them. Their defence then moves to a ‘bad apple’ manager who acted independently and has since been dealt with. Then there is a settlement with no acceptance of guilt and finally, reluctantly, an apology. There is a mess to clean up and each of the groups is at a different stage of contrition, but they are all paying.
Big Pharma has been chastened with massive fines. A key player is Purdue Pharma, who in the UK owns Napp. They got the ball rolling by bringing to market OxyContin in the 1990s claiming, since it was a slow-release formulation, it could not cause addiction. There was no evidence for this claim, yet they got a licence to market the medicine. Their marketing strategy focused on addressing a huge unmet clinical need for pain, since doctors traditionally avoided opioids in chronic pain due to addiction risk. It was an ominously successful strategy. Other manufactures got into the game, including Johnson and Johnson and Teva.

role in the opioid pandemic, but once they controlled their product supply by shutting down the ‘pill-mills’ the backfill came from the Mexican cartels who supplied illegal heroin and fentanyl into affected communities, with devastating effect. It is a tragic example of how, when you turn on the tap and the washer fails, when you turn off the water, it still flows.
The biggest fall from grace happened to the Sackler Family, owners of Purdue Pharma. Their $8.3 billion settlement bankrupted the business and, ironically, they lost control of the family trust fund used for their generous philanthropic work and other good deeds. Initially, the Sacklers used a defence straight out of the National Rifle Association’s handbook — something like, there’s no such thing as a bad drug (gun), just bad people who misuse drugs (guns).
Finally, and after considerable prompting and public humiliation, the Sackler family conceded that their over-zealous marketing, largely based on no evidence, was the main source of the epidemic. In a carefully-worded statement that accompanied their settlement, they said ‘sorry’. Sort of. They finally seem to be accepting that, despite denials for over 20 years, they really did do something wrong.

Johnson & Johnson are less contrite. They agreed to pay a total of over $5 billion to settle claims that the company fuelled an opioid addiction crisis in New York State and in other jurisdictions. The company, in settling, however, did not admit liability or wrongdoing.
The main consultant implicated is McKinsey & Company, which has agreed to pay nearly $600 million to settle claims it ‘turbocharged’ opioid sales. They still claim they are innocent, but the settlements came after lawyers unearthed a trove of documents showing things differently.
One email revealed that after the Federal government reached a settlement with Walgreens Boots Alliance (WBA) in 2013 to crack down on illegal opioid prescriptions, sales began to fall. At this point, McKinsey recommended that Purdue “lobby Walgreens” to “loosen up”.
Wholesalers McKesson, Cardinal Health and AmerisourceBergen agreed to pay a combined amount. McKesson said that this $21 billion, which the three distributors will pay over 18 years, will largely be used to remediate the opioid crisis. The wholesalers seem to be accepting that they had a role in identifying and reporting unusually large deliveries of opioids to certain locations, something they failed to do. McKesson owns AAH and the Lloyds pharmacy group.
Pharmacy multiples — Walmart, Walgreens (WBA) and CVA — are also in the dock. The Boots Chain and Alliance wholesaler owners, Walgreens, have a legal defence that states simply, ‘we did nothing wrong’. What would be wrong, it argues, would be for its pharmacists, dispensing legally prescribed medicines, to interfere with the doctor-patient relationship by querying what was prescribed and even refusing to dispense. Initially, for me this displays a stunning ignorance of the fundamental professional and ethical responsibilities of a pharmacist.
WBA’s senior management and Board seem to be confusing the pharmacist’s role with that of a dispensing robot. The fact that WBA had in place incentive payments for pharmacists based on opioid prescription numbers and didn’t see this as a problem says a lot. They also ran businesses of such efficiency, dispensing workloads hampered proper clinical assessment and scrutiny of prescriptions by their pharmacists. Of course, their pharmacists had a responsibility to speak up.

In community pharmacy, there will always be tensions between professionalism and commercialism. Pharmacy business owners must make a profit and the pharmacists employed must also act in the best interests of their patients. Oversight and regulation is supposed to assure this. So

engrossed in the US free-market ideology are the US pharmacy multiples, they seem to have lost sight of this. As they agree settlements across the US, while still not accepting liability, they need to reflect on how they might in the future do business better.
These settlements could have huge implications for pharmacy in other countries, especially in the UK and Ireland. We are nowhere near the scale of the US problem, but our opioid use for chronic pain management is out of control and GPs are struggling to manage patients addicted to, for example, co-codamol 30/500. Opioids are largely useless in the treatment of chronic pain, but I find it very difficult to get this message across to patients. In the last 10 years, I have witnessed a huge increase in the use stronger opioids, in spite of good evidence that they don’t work. For pharmacy groups, and many multiples too, to simply state they as pharmacists were just doing their job while hundreds of thousands die will not cut it in the communities destroyed by this stunning example of corporate greed.
I appreciate how hard it would be for individual pharmacists to unilaterally tackle this problem. But if we have any purpose, this is it, and I now see that WBA, for example, are taking proactive steps to support their pharmacists to tackle opioid addiction and its consequences. Prevention of diversion would be a start by reporting doctors prescribing large amounts of opioids, identifying patients getting prescriptions from multiple GPs, and calling-out dangerous drug combinations, such as opioids and benzodiazepines. Clearly, patient education on effective pain management would be positive step. It would also signal that we accept there is a problem that needs addressed and we want to be part of the solution.

Contributor Information

Terry Maguire owns two
pharmacies in Belfast. He is an
honorary senior lecturer at the School
of Pharmacy, Queen’s University
Belfast. His research interests include
the contribution of community
pharmacy to improving public health.