A recent investigation by The New York Times has revealed that drug manufacturers, including Purdue Pharma, secretly paid pharmacy benefit managers (PBMs) to avoid imposing restrictions on the distribution of prescription opioids.
These deals contributed to the unchecked flow of powerful painkillers like OxyContin during a time when the opioid crisis was devastating communities across the United States.
Pharmacy benefit managers (PBMs) wield enormous influence over the healthcare system. These middlemen determine which medications insurance plans will cover and negotiate discounts with drug manufacturers.
While PBMs are meant to act in the interest of patients and insurers by controlling drug costs and ensuring safe practices, evidence shows that some accepted payments to prioritize profit over public health.
According to documents reviewed by The New York Times, PBMs such as Express Scripts, CVS Caremark, and Optum Rx negotiated lucrative rebate agreements with drug manufacturers. In exchange, PBMs agreed not to enforce safeguards like limiting the number of opioid pills dispensed or requiring additional approvals for high-dose prescriptions.
Internal records from Purdue Pharma explicitly outlined their strategy: offer rebates to PBMs in order to eliminate restrictions on OxyContin prescriptions. This ensured widespread access to the drug without delays or additional checks, fueling overprescribing and increasing the risk of addiction and overdose.
The investigation revealed that Purdue’s annual payments to PBMs more than doubled over the years, reaching $400 million in 2012. These rebates incentivized PBMs to avoid implementing stricter opioid safety measures, even as the epidemic claimed tens of thousands of lives.
Despite the escalating crisis, PBMs often prioritized financial gain over patient safety. In some cases, when insurers attempted to restrict opioid prescriptions, PBMs intervened by highlighting the potential loss of rebates. This pressure led to decisions that prioritized profits over efforts to curb the epidemic.
For example, in one instance, Purdue collaborated with a PBM to convince an insurer to increase its limit on the number of OxyContin pills prescribed to patients. Similarly, other opioid manufacturers used financial incentives to reverse restrictions on their drugs, further contributing to the epidemic.
Documents also revealed internal disagreements within PBMs about the balance between profit and public health. Some executives raised concerns about the ethical implications of prioritizing rebates over safety, but these objections were often overruled in favor of maintaining contracts with opioid manufacturers.
In the mid-2010s, as public and regulatory scrutiny increased, PBMs began to implement measures to reduce opioid overprescribing. However, by then, the damage had already been done. Between 1996 and the early 2010s, millions of prescriptions for high-dose opioids were written, many of which could have been prevented by earlier interventions.
Express Scripts and other PBMs introduced new opioid safety programs in 2017 and 2018, imposing limits on doses and requiring prior authorizations. While these measures eventually contributed to a decline in opioid prescriptions, critics argue they came too late to prevent the widespread devastation caused by the epidemic.
In the aftermath of the opioid crisis, PBMs have largely escaped the level of legal accountability faced by manufacturers, distributors, and pharmacies. However, recent lawsuits and investigations have brought their role in the crisis to light.
The evidence underscores a critical lesson: unchecked corporate influence in healthcare can have catastrophic consequences. For communities grappling with the opioid epidemic, it is a stark reminder of the need for transparency, accountability, and a commitment to public health over profit.