A Review of Errors and Misdirection in the US National Opioid Settlement:

Original author: Maria Higginbotham [https://www.facebook.com/maria.higginbotham.14]

Sponsor for Publication: National Campaign to Protect People in Pain

Recap of the National Opioid Settlement

🚨 Key Harms to Pain Patients from Settlement Terms

(pp. 478–520)

1.  Distributor-Imposed Thresholds on Pharmacies

“Distributors agreed to implement… ordering thresholds to detect suspicious opioid orders… based on a pharmacy’s order history and regional comparisons.”

🔴 Impact:

• Pharmacies are being algorithmically red-flagged for filling any controlled substances, not just suspicious ones.
• As seen in real-world reports, pharmacies have refused to fill legitimate prescriptions, including for pain medications like buprenorphine and long-term opioids, out of fear of exceeding these thresholds.

This creates a chilling effect on care: pharmacies err on the side of non-dispensing, hurting patients with legitimate needs.

2.  “Red Flag” Prescription Validation Systems at Pharmacies

CVS, Walgreens, Walmart, Kroger, and others must maintain “a prescription validation process that identifies potential red flags.”

🔴 Impact:

• Vague and inflexible “red flag” systems may wrongfully label patients as suspicious simply for: High opioid doses (even when stable) Using multiple prescribers (e.g., pain + palliative + mental health) Paying cash or needing early refills due to travel/surgery
• These systems are often automated and not subject to clinical review, leading to denied prescriptions and pharmacy discrimination.

3. Pharmacist Employment Consequences Tied to Controlled Substances

 “Prohibit pharmacists from facing negative employment consequences for failing to meet targets that depend on sales of controlled substances.”

🔴 Problem:

• While intended to reduce sales pressure, this provision incentivizes pharmacists to avoid filling controlled substances altogether—especially opioids.
• Pharmacists now feel empowered to deny care preemptively without consulting prescribers.

4. Injunctions Against “High-Dose” Prescribing

Endo and Mallinckrodt must “refrain from manufacturing, promoting, or distributing opioid products that exceed 30 milligrams of oxycodone per pill.”

🔴 Impact:

• 30 mg oxycodone caps artificially limit options for pain patients on stable, high-dose therapy.
• This leads to increased pill burden, cost, and difficulty for patients with serious conditions.
• Patients already stabilized on higher-dose formulations are being forced to taper or switch unnecessarily.

5.  No Protection for Pain Patients in Abatement Use Restrictions

85% of funds are required to be used for opioid “abatement,” primarily for OUD treatment, MAT, and naloxone distribution.

🔴 Impact:

• Nothing earmarked for improving pain care or supporting abandoned patients.
• Pain patients are being blamed and excluded from the very funds generated by their suffering.
• No requirement to fund balanced provider education on pain management.

🧨 Summary: Why It’s “Unbelievably Bad” for Pain Patients

• The settlement institutionalizes pharmacy refusals, red-flagging, and surveillance practices that harm compliant pain patients.
• It gives legal cover to policies that have led to involuntary tapering, mislabeling of patients as “drug-seeking,” and pharmacy discrimination.
• No safeguards or funding are allocated to protect those with rare, progressive, or palliative pain conditions.
• Patients who were lawfully prescribed opioids have no path to restitution—only punishment by proxy.

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A footnote: these findings closely parallel those of Pat Irving, RN and former National Patient Safety Educator for the Kaiser Permanente insurance system, published in Pain News Network.