A professor of pharmacy called as an expert witness by the State of Florida on April 25 told a jury that of the prescriptions he reviewed between 2007 and 2020, Walgreens Pharmacies failed to investigate and resolve 89.3 percent of the suspicious prescription opioid drug orders received.
“Why is this concerning?” a state's attorney asked.
“Because that’s a lot of medicine,” Paul Doering, a former professor of pharmacy responded.
“What did Walgreens pharmacists do (to check suspicious orders) as indicated from the ordering data?”
“Nothing,” Doering said.
A displayed graphic said, “In many cases Walgreens saw red flags but dispensed (opioids) anyway.”
The trial in Pasco County in Port Richey is being streamed live by Courtroom View Network.
The latest court case against Walgreens, the country’s largest drug chain, was originally filed by former Florida Attorney General Pam Bondi in 2018. She accused the company of flooding the state with opioid pills and creating an epidemic of addiction. The current Attorney General Ashley Moody now directs the lawsuit.
The epidemic allegedly started in the 1990s when the medical community, misled by drug manufacturers and distributors, relaxed its former conservative policy of prescribing opioids mostly for end-of-life and cancer treatments, and instead allegedly recklessly prescribed opioid drugs for less serious non-cancer conditions. Anti-drug diversion in-house programs required of the companies by the the U.S. Drug Enforcement Administration were ineffective, plaintiff attorneys contend.
Florida, along with West Virginia and Alabama has had one of the highest rates of opioid addiction in the country. Attorneys maintain that Walgreens has a history of illegal dispensing of drugs, some of the activity taking place in the parking lots of area stores.
In 2013, Walgreens agreed to pay $80 million for violating the Controlled Substances Act and negligently allowing drugs to be diverted for abuse and black market sales. The DEA served Walgreens with suspension orders because of drugs being diverted. Walgreens at the time was the largest provider of the drug OxyContin in the state.
Defense attorneys have countered the state by arguing that the DEA in its maximum quota system allowed too many drugs to be manufactured. They also argued that others caused the epidemic - pharmaceutical companies like Purdue Pharma, distributors like McKesson Corp. and AmerisourceBergen, internet pharmacies and irresponsible clinics known as “pill mills.”
Purdue Pharma, owned by the Sackler family, reached an $8.3 billion settlement agreement in 2020 after admitting company officials had knowingly conspired to aid doctors dispensing the drugs without a legitimate medical purpose.
The original Florida lawsuit included as defendants CVS Pharmacy, Teva Pharmaceutical, Allergan and Endo International. Those companies settled with the state for more than $878 million last month.
The trial which began on April 11 took a two-day postponement last week when a juror tested positive for the COVID virus.
Doering, a retired professor from the University of Florida Department of Pharmacotherapy, works as a consultant in the pharmacy industry. He said the role of the pharmacist was to plug any leaks in the controlled substances (opioids) dispensing system.
“Pharmacists are in a key position,” he said.
Doering explained the different types of suspicious orders that pharmacists are supposed to spot and investigate. They included pharmacy shopping, or pill takers going from pharmacy to pharmacy, doctor shopping, visiting more than one doctor for prescriptions, patient caravans and opioid cocktails (mixing pills).
“Information about people shopping pharmacies, that information is available to Walgreens pharmacists,” Doering said. “With a caravan the patients will arrive in a van at the pharmacy and one by one enter.”
Doering said "cocktail" is the term used to describe the mixing of drugs, for example the opioid OxyContin taken with alpazolam (also called Xanax) used to treat anxiety, and carisoprodol, a muscle relaxer that blocks pain.
“Why is this dangerous?”
“The side effects,” Doering answered. “There are three drugs (combined) and one can intensify the other.”
Doering described a number of situations where a pharmacist should become suspicious of an opioid drug order. If a patient drives a far distance to visit a pharmacy, or doesn’t want to use insurance to pay though they have insurance. Also considered a red flag is a patient using street (slang) names for drugs, presenting a prescription for multiple patients, visiting multiple prescribers, or paying for a drug with cash.
Other warning signs include a second prescriber filling a different prescription for a patient in the past two weeks, or two prescriptions coming from different zip codes in a 30-day period. Another sign is a patient who orders more pills before their previous prescription runs out.
“After a red flag, this is where investigation begins,” Doering said. “You must talk to the prescriber.”
“How can a red flag be resolved?”
“A satisfactory explanation in the patient’s best interest,” Doering said.
Doering said pharmacists are required to document their findings and those at Walgreens had been told so in their instruction materials.
His study said that 46.2 percent of Walgreens prescriptions had at least one red flag attached to them, and 27 percent two red flags.
Dispensing data showed Walgreens Pharmacies in Florida between 2006 and 2020 filled 91 million prescriptions. Of those, 35.7 million could be considered “cocktail” prescriptions.
During cross examination, Steve Derringer, attorney for Walgreens, attempted to undermine Doering’s testimony, calling attention to his not being currently a licensed pharmacist and his pay as an expert witness.
“Most pharmacists want the best for the patients they serve,” Derringer said.
“Most of them,” Doering agreed.
“You agree it’s up to the pharmacist to use their independent judgement (making a prescription).”
“I believe that with all my heart,” Doering said.
“Independent professional judgment depends on the pharmacist knowing the patient.”
“Yes,” Doering said. “A reasonable pharmacist would do the things I’ve discussed.”
A pharmacist has an obligation to fill valid prescriptions.”
“As long as it’s in the best interest of the patient,” Doering said.
“A red flag is not an indication a prescription is invalid?”
Doering agreed.
Derringer said Doering had formed his opinion that 89 percent of Walgreens prescriptions had been unresolved without talking to a single doctor.
Doering agreed he had not.
“The last time you filled a prescription was in the early 1970s?”
“That’s correct,” Doering said.
“Your license (pharmacy) expired in 2017?”
“Correct.”
Derringer asked Doering why he had not taken an exam to restore his license. Doering said he had work and family commitments.
“I want to take the exam on my time table, not yours,” Doering said.
“You’re paid $400 per hour (to testify).”
Doering agreed.
Asked how much he had been paid to date for his work on the case, Doering said the money from the state was still owed.
“It could be over $150,000," he said. "It’s been two years. That’s a lot of hours.”
“About 80 percent of your income is serving as a plaintiff witness in litigation.”
“This is my job.”
“You didn’t speak to any patient who thought their prescription should not have been filled.”
“Correct,” Doering answered.
Derringer displayed a 2002 document that said the Florida Board of Pharmacists were concerned about the “inadequate treatment of chronic pain.”