SAN FRANCISCO (KRON) — Walgreens is guilty of “substantially contributing” to San Francisco’s opioid addiction epidemic, a federal judge ruled on Wednesday.

Walgreens flooded the city’s pharmacies with millions of opioid pills without safeguards to prevent suspicious prescriptions from being filled for 14 years, U.S. District Judge Charles Breyer said. The judge made his ruling based off a three-month-long trial, City and County of San Francisco v. Purdue Pharma, also known as the “Opioid Trial.”

San Francisco’s landmark win in court holds Walgreens liable and gives a voice to countless voiceless overdose victims who lost their lives, City Attorney David Chiu told reporters Wednesday.

Walgreens is the largest retail pharmacy chain in San Francisco. Evidence presented at the trial showed that between 2006 and 2020, Walgreens distributed and dispensed over one hundred million prescription opioid pills in the city.

The Controlled Substances Act and its implementing regulations impose duties on distributors and dispensers of prescription opioids. In exchange for the privilege of distributing and profiting from prescription opioids, “Walgreens has regulatory obligations to take reasonable steps to prevent the drugs from being diverted and harming the public. The evidence at trial established that Walgreens breached these obligations,” the judge wrote in his ruling.

CSA regulations require distributors to implement and maintain a system for identifying suspicious orders of opioids. Suspicious orders of opioids must be halted and reported to the DEA. Evidence presented during the trial “established that Walgreens violated this regulatory duty for several years. It did not maintain an effective system for identifying suspicious orders. It shipped thousands of suspicious orders to its pharmacies without investigation,” the judge wrote.

Breyer wrote, “The opioid epidemic has plagued San Francisco for over twenty years. The number of individuals who die annually from opioid overdoses continues to climb. Thousands of city residents, from all walks of life, struggle with addiction. Widespread opioid use has strained the city’s hospitals. It has exacerbated crime and homelessness.”

Chiu told reporters, “This crisis did not manifest out of thin air. Walgreens significantly contributed. Walgreens did not red flag suspicious orders and pharmacists were pressured to fill, fill, fill. Walgreens flooded our city with opioids.”

“(Filling) prescriptions should be based on science and health, not marketing and profits,” Chiu said.

Once the opioid epidemic broke out, Walgreens tried to shift the blame away from its pharmacies, the city attorney said. Chiu said it was ironic when Walgreens closed several of its locations in San Francisco neighborhoods due to crime and homelessness, when Walgreens was to blame for creating that environment.

Opioids are a class of drugs that include oxycodone, morphine, hydrocodone, heroin, and fentanyl.

Between 2015 and 2020, San Francisco saw a 478 percent increase in opioid-related overdose deaths, and in a typical day at the Zuckerberg San Francisco General Hospital Emergency Department, 25 percent of visits were opioid-related.

The amount the pharmacy chain giant must pay San Francisco will be determined in a later trial.

Walgreens was the only defendant named in City and County of San Francisco v. Purdue Pharma who refused to agree to a settlement. Two more defendants, opioid manufacturers Allergan and Teva, reached a $54 million settlement agreement last month.

Rather than wait for the judge’s ruling, Allergan and Teva, agreed to pay San Francisco $34 million in cash and provide the city $20 million worth of the overdose reversal drug, Narcan. Following the agreement, Allergan and Teva were severed from the trial.

At the start of the trial, the City Attorney’s Office secured a $10-million settlement agreement with the pharmaceutical company Endo, as well as a $60-million settlement with opioid manufacturer Johnson & Johnson.

The science of opioid addiction

Dr. Anna Lembke, a professor and medical director of addiction medicine at Stanford University, explained opioid addiction as a change in brain chemistry.

Opioids bind to pain receptors, temporarily relieving pain, and trigger the release of dopamine, a neurotransmitter that causes feelings of pleasure and reward.

In response to repeated additional releases of dopamine from opioid use, the brain begins to downregulate the amount of dopamine it naturally produces. The result is a dopamine-deficient state, in which the brain is producing less dopamine and the user is experiencing less pleasure and more pain than they were before opioid use began.

In a dopamine deficient state, a user needs opioids to return to their previous dopamine baseline and to avoid the pain of prolonged dopamine deficiency, Dr. Lembke said. Users need opioids not to feel good but just to restore a level balance and feel “normal.” Opioid users in this state are physically dependent on the drugs.

Someone taking opioids for a relatively short period of time can develop physical dependence and experience withdrawal if they stop taking opioids. Users report feeling “trapped” in a cycle of using opioids to escape from withdrawls.

Dr. Lembke explained, “The individual needs more and more to get the same effect and ultimately is physically dependent and experiences painful withdrawal when they stop. It can take a very long time after the individual has stopped using their drug for the brain to reset itself to normal dopamine levels.”

Opioid experts said addiction affects people from all walks of life, regardless of age, ethnicity, or socioeconomic status. The neural pathways affected by opioid use are common across all people, which makes everyone vulnerable to opioid addiction.

The process of tapering off opioids “is time-intensive and requires substantial support from
clinicians and other providers in the healthcare system,” Dr. Lembke said. Detoxification and rehabilitation centers can be utilized to support a person’s recovery.