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Opioids

Maia Anderson

Healthcare Brew delivers the latest news and trends in healthcare.

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The opioid epidemic has been a defining public health crisis in the US for the past quarter century. 

With more than 800,000 people dead from overdoses over nearly 25 years, it’s hard to find an event—outside of the 

—that has impacted the US healthcare system more. The economic cost of opioid use disorder and opioid overdoses in the US was estimated to be more than $1 trillion in 2017 alone, according to 

Today, the number of overdose deaths has 

. But experts warn impending changes to Medicaid could slow that progress.

Further, overdose deaths are still higher than they were pre-pandemic, Thuy Dieu Nguyen, an assistant professor of health management and policy at the University of Michigan School of Public Health, told Healthcare Brew.

“We still have an ongoing opioid crisis,” she said.

The CDC breaks the opioid epidemic into three waves.

The first began in the 1990s, when doctors started prescribing more opioids for pain control, driven largely by Purdue Pharma’s OxyContin hitting the market in 1996. The second wave that began in 2010 saw an increase in heroin deaths, as the drug became cheaper and more available in the US. The third wave began in 2013 as synthetic opioids, primarily fentanyl-based drugs, rose in popularity.

The CDC first called the opioid crisis an “epidemic” in 2011, and in October 2017, President Donald Trump declared it a public health emergency.

 targeted opioid manufacturers, pharmaceutical distributors, and pharmacies for allegedly “aggressively marketing” the drugs while “downplaying addiction and overdose risks.”. In 2019, Purdue Pharma, the maker of OxyContin, 

. Though the company had profited $35+ billion from opioid sales, it was later forced to 

But what didn’t receive much legal attention—until recently—is the role of 

 (PBMs), which negotiate with drug companies to create formularies for insurers.

A group of lawmakers asked the Department of Justice in December 2024 to investigate 

 in the opioid epidemic, saying in a letter that 

 and a review of confidential files suggested the Big 3 PBMs—CVS Caremark, Express Scripts, and Optum Rx—“colluded and conspired to steer patients toward OxyContin in exchange for $400 million.”

 in December they offered payers the option to restrict opioid prescriptions.

After skyrocketing during the pandemic, the number of opioid-involved deaths started falling in 2023 for the first time since 2018, according to CDC data.

Between 2022 and 2023, the number of overdose deaths involving synthetic opioids fell by 2%, heroin by about 33%, and prescription opioids by almost 12%.

Further, provisional CDC data shows total drug overdose deaths fell about 27% from 110,037 to 80,391 between 2023 and 2024.

Experts aren’t sure why, exactly, overdose deaths have started dropping so significantly, but Nguyen said there are a few potential explanations.

First, some experts think that because fentanyl overdoses have already killed so many people in recent years, the number of high-risk drug users is shrinking, she said.

Second, harm reduction measures, like increased access to naloxone, an opioid overdose reversal drug, may be working. In March 2023, the FDA 

 over-the-counter Narcan (a brand-name naloxone), which can also be bought online.

“The interventions are now working,” Nguyen said. “People have easier access to naloxone, fentanyl testing strips, or certain things that have helped individuals to cope with deadly fentanyl products.”

Access to other opioid use disorder treatments, such as buprenorphine, has also been expanded significantly, Nguyen said. For instance, during the pandemic, the Drug Enforcement Agency and Substance Abuse Mental Health Services Administration allowed providers to prescribe buprenorphine after an audio-only telehealth call instead of requiring patients to go in person. That rule became permanent in January 2025.

And policies passed during the pandemic, including 

 that allowed beneficiaries to stay enrolled through the public health crisis, likely helped, she added. 

 shows that 47% of nonelderly adults with opioid use disorder are Medicaid beneficiaries.

Additionally, many states no longer require prior authorization for at least one type of buprenorphine, Heather Saunders, a senior research manager for KFF’s program on Medicaid and the uninsured, told us. That’s led to an increasing number of prescriptions for the treatment, she added.

Potentially the biggest threats to this progress are the looming 

, as Medicaid “finances the largest share of medication-assisted treatment,” Saunders told us.

, which was signed into law on July 4, cuts Medicaid funding by about $1 trillion over the next 10 years and puts work requirements in place, which means beneficiaries must prove they spend 80 hours per month working, going to school, or doing other approved activities like community service.

The added paperwork burden that comes with work requirements may cause coverage gaps, which could raise the risk of overdose deaths, Saunders said.

Stopping opioid use disorder treatment is linked to a 6x higher mortality risk for the first four weeks after interrupting treatment, according to the KFF analysis, which Saunders co-authored.

 overall will become uninsured,” she said. “So, to the extent that includes people with opioid use disorder, that might have implications for them being able to access treatment continuously.”

Where the opioid epidemic stands amid Medicaid cuts, work requirements 

Cuts to Medicaid funding could have a chilling effect on recent progress curbing opioid overdose deaths. 

Where the opioid epidemic stands amid Medicaid cuts 

Cassie McGrath

Second time’s the charm? That’s what Rite Aid seems to be hoping.

The retail pharmacy is reportedly considering filing for another bankruptcy as it attempts to get back on its feet after years of financial complications, according to the 

. The Philadelphia-based retailer is also reportedly thinking of selling individual assets to avoid a second Chapter 11 in less than two years.

 in October 2023 after struggling to keep up with competitor retail pharmacies CVS and Walgreens. It was also dealing with 

 about its pharmacy benefit manager, Elixir, as well as 

 in September 2024 after reducing its debt by $2 billion.

However, WSJ reported the company is now working with Paul Weiss, a global law firm, to discuss additional options, as further liquidation of its assets—either with or without another bankruptcy—looks to be on the table.

 Rite Aid is also seeking a debtor-in-possession loan, which is financing that would allow the company to stay open amid a second bankruptcy. The report added the company may sell some stores and close others, and is reportedly working with investment firm Guggenheim Securities to hammer out those details.

Rite Aid has already closed about 800 of the 2,000 stores it had before filing for bankruptcy in 2023.

 in March the company was allegedly looking for a loan that would allow it to add inventory to its stores in exchange for hitting financial targets.

Rite Aid did not respond to a request for comment by the time of publication.

Earlier this week, Walgreens, one of Rite Aid’s top competitors, reached a 

 with the federal government to resolve allegations it had illegally doled out opioids and other controlled substances to patients. This comes as the pharmacy retailer is in the process of 

A sign is posted in front of a Rite Aid store on June 20, 2024 in San Rafael, California

Rite Aid is considering another bankruptcy 

The retailer previously filed for bankruptcy in October 2023. 

The retail pharmacy giant was accused in January of illegally filling “millions” of prescriptions for opioids and other controlled substances from August 2012 through March 2023, in violation of the Controlled Substances Act.

Now it owes a hefty sum after reaching a settlement with the Justice Department, the Drug Enforcement Administration, and the Department of Health and Human Services Office of Inspector General. In a statement on April 21, the federal agencies alleged Walgreens had also asked for Medicare payments for some of the dispensed opioid prescriptions, which would violate the False Claims Act.

While opioid deaths are on the decline (down 24% from 114,000 to 87,000 between October 2023 and September 2024, 

), the drugs killed 727,000 people from 1999–2022, the CDC also reported.

In the suit, the government agencies accused Walgreens of filling prescriptions for controlled substances “despite clear red flags” they weren’t legitimate.

They also alleged Walgreens pressured staff to fill prescriptions quickly, therefore not giving staff time to make sure they were legal.

“Pharmacies have a legal responsibility to prescribe controlled substances in a safe and professional manner, not dispense dangerous drugs just for profit,” US Attorney General Pamela Bondi said in a release.

According to the settlement agreement, Walgreens will have to pay an additional $50 million if it’s sold, merged, or transferred before FY 2032.

The settlement comes after Walgreen’s announced it 

Fraser Engerman, senior director of media relations and issues management at Walgreens, told Healthcare Brew in a statement that the company “strongly disagree[s] with the government’s legal theory and admit[s] no liability.”

“This resolution allows us to close all opioid related litigation with federal, state, and local governments and provides us with favorable terms from a cashflow perspective while we focus on our turnaround strategy,” he added.

Neither the federal government nor Walgreens mentioned the looming sale to Sycamore.

Walgreens pays $300m settlement over opioid prescription allegations 

More than 727,000 people died from opioids between 1999 and 2022, according to the CDC.  

illustrated headshot of caroline catherman, healthcare brew reporter

Caroline Catherman

As every chronic procrastinator knows, nothing feels better than an extension on a due date.

 relief for the US Drug Enforcement Administration (DEA) and the Department of Justice (DOJ) to 

 the effective date of two new telehealth rules from March 21 to Dec. 31.

The rules would permanently expand some temporary telehealth flexibilities for 

—a medication used to treat opioid dependence—and for Department of Veterans Affairs (VA) clinicians to prescribe controlled substances.

These telehealth flexibilities were enacted during the pandemic and are set to expire Dec. 31. But telehealth clinicians have long called for a 

, and these rules—two of three final controlled substances guidelines released on Jan. 16—were part of that solution.

“Unfortunately, the DEA’s decision fosters uncertainty for both healthcare providers and their patients,” Hari Prasad, CEO of mobile patient intake management system Yosi Health, told Healthcare Brew. “Delaying the implementation of these rules signals hesitation at a time when we should be prioritizing access and continuity of care for vets.”

This isn’t the first extension, either. The rules were initially set to take effect on Feb. 18, but were pushed back to March 21 after President Trump took office and issued a regulatory freeze.

Rule one, Expansion of Buprenorphine Treatment via Telemedicine Encounter, would let telehealth providers prescribe the drug for up to six months without an in-person visit. Pre-pandemic, a patient needed to have an in-person medical evaluation to get more than an initial 30-day supply of buprenorphine.

The other rule, Continuity of Care via Telemedicine for Veterans Affairs Patients, would give 

 to VA practitioners, allowing them to prescribe controlled substances remotely to patients they have never met in person, as long as that patient has received an in-person medical exam from another VA clinician.

 to prescribe Schedule II–V controlled substances—such as hydrocodone, oxycodone, Adderall, or Ritalin—without an in-person visit.

Christopher Adamec, executive director of industry group Alliance for Connected Care, 

 he felt these laws didn’t go far enough to expand telehealth access, adding that the buprenorphine rule’s six-month limit means a doctor could be forced to cut off treatment “in a potentially harmful way when the patient needs it most.”

The DOJ said in federal documents that it’s postponing the effective date to address public comments and to add more time to review “any questions of fact, law, and policy that the rules may raise.”

Mature doctor using digital tablet at desk. Male medical professional is giving online consultation during coronavirus outbreak. He is in clinic.

DEA again delays new telehealth prescribing rules for veterans, buprenorphine

Federal government officials—they’re just like us! (Procrastinators.)

In the final days of President Joe Biden’s tenure, the Drug Enforcement Administration (DEA) announced three new rules to allow medical providers to prescribe controlled substances via telehealth.

These rules would make temporary flexibilities—enacted in 2020 following difficulties getting prescriptions during the Covid-19 pandemic—permanent.

 for a permanent extension, but there are still a few hiccups in the fine print of this proposal that need to be addressed, Christopher Adamec, executive director of industry group Alliance for Connected Care, told Healthcare Brew.

He hopes the Trump administration will make some tweaks. The White House didn’t provide an answer on that by deadline.

“The Biden administration put forward a great framework, but there are some pretty serious issues with it that would aggressively curtail the way telehealth is used today,” Adamec said.

The DEA’s new rules include one that allows telehealth providers to prescribe buprenorphine—a medication used to help treat opioid dependence—for six months. Previously, a patient needed to have an in-person medical evaluation to get more than 30 days of buprenorphine.

This rule is finalized and set to take effect February 18, though the Trump administration could nix those plans.

The problem here: the six-month limit, Adamec lamented. Not all patients will be able to secure an in-person appointment after six months.

“[A clinician may] have to cut off treatment in a potentially harmful way when the patient may need it most,” he said.

Another proposed rule allows providers to get a special registration to prescribe Schedule III–V controlled substances without an in-person visit, as well as an advanced telemedicine prescribing registration to prescribe Schedule II–V controlled substances without an in-person visit.

However, the new proposed rules say that even if providers sometimes prescribe Schedule II drugs via telehealth, at least 50% of their Schedule II prescriptions need to be done after an in-person visit. This makes it impossible to prescribe Schedule II drugs—such as hydrocodone, oxycodone, Adderall, or Ritalin—as a telehealth-only practice, Ademac said.

Telehealth providers would also be required to be in the same state as the person they’re remotely prescribing a Schedule II controlled substance to, with the rationale that it’s easier for state agencies to monitor prescribing practices.

“That’s a challenge for expanding access to treatment for patients that may be in an area where there are clinician shortages,” Adamec said.

Not everyone found issues with the rules, however.

“The DEA’s new rules and registration requirements demonstrate a much-needed, mindful approach to balancing telehealth access with patient safety,” Hari Prasad, co-founder and CEO of mobile patient intake management system Yosi Health, told Healthcare Brew via email.

Doctor speaking to patient from a digital health cross

Are new DEA controlled substance telehealth guidelines final? Trade group hopes not

Prescribing rules promise flexibility but leave room for improvement, industry experts say.

Are new controlled substance telehealth guidelines final? Trade group hopes not

 (PBMs) played a hidden—but important—role in the opioid crisis.

The outlet said it reviewed documents including contracts, emails, and financial data, and learned that in exchange for higher rebates, PBMs restrained formularies—the list of drugs insurance will cover—from enacting safeguards like strict quantity limits.

While PBMs began implementing more opioid restrictions under federal pressure in 2017, this came after years of lucrative rebates for the 

In 2012, drugmaker Purdue Pharma paid PBMs about $400 million a year in rebates, the NYT found. An internal presentation obtained by the NYT allegedly showed Purdue instructing employees to “offer rebates to remove payer restriction.”

In statements, PBMs defended themselves to the NYT, arguing they offered public and private insurers and programs like Medicaid the option to restrict opioids. But the intermediaries reportedly also sometimes pushed those clients to go easy on opioid manufacturers, the NYT said.

In 2003, for instance, UnitedHealthcare was planning a monthly cap on Purdue’s drug OxyContin. But an executive from PBM Merck-Medco (which later became part of Cigna’s PBM Express Scripts) warned them that could cause a “potential loss of rebates,” according to the Times.

“That information convinced the UHG [UnitedHealth Group] team to change,” the executive wrote to Purdue in a communication obtained by the NYT.

UnitedHealthcare still issued a cap—124 pills per person per month—but that cap was more than double its initial proposal of 60.

This investigation follows lawsuits filed over the last few months from Michigan, Kentucky, Mississippi, and other states against PBMs for their roles in exacerbating the opioid crisis by reducing safeguards.

Beyond that, the Federal Trade Commission has 

 the country’s top three PBMs—CVS Health’s Caremark, Express Scripts, and UnitedHealth Group’s Optum Rx—alleging they artificially inflated insulin prices.

PBMs had hidden role in opioid crisis, NYT investigation finds

Documents show pharmacy benefit managers helped drugmakers like Purdue Pharma dole out opioids in exchange for payouts.

The number of people in the US dying from drug overdoses is falling for the first time in years—and it’s falling quickly.

Nationwide, overdose deaths fell 12.2% between April 2023 and April 2024 from 110,771 to 97,309, according to 

 released in September. In comparison, overdose deaths fell by 3% between 2022 and 2023, the first annual decrease since 2018 when the number of deaths was 67,367.

Data from individual states shows even more drastic declines. In Ohio, for example, overdose deaths are down 32.6% so far this year compared to last, according to nonprofit 

. And in Vermont, state health department data from January to June of this year 

 overdose deaths have fallen about 16% compared to the average number of overdose deaths from the same period over the past three years.

Despite this, some experts are hesitant to celebrate—especially since there were still more than 100,000 overdose deaths in the US last year.

“I think we have to be careful when we get optimistic and see a slight drop in overdose deaths,” Dan Salter, executive director of the federal High Intensity Drug Trafficking Areas (HIDTA) program for the Atlanta–Carolinas region, told 

. “The last thing we want to do is spike the ball.”

It’s too soon to know for sure, experts told NPR. But there are some known factors that have likely contributed, such as the increased accessibility of naloxone, an opioid overdose reversal drug.

 nasal sprays—Narcan and RiVive—making the drug available without a prescription for the first time. And in May 2024, Walgreens 

 its own brand of naloxone priced at $34.99 for two doses, about $10 cheaper than Narcan.

The Biden administration has also taken steps to increase naloxone’s availability. In December 2023, the Department of Health and Human Services 

 recommending all federal facilities keep naloxone on site.

And there are many state initiatives to increase naloxone access. For example, Michigan, Kentucky, and California have naloxone vending machines that dispense the drug for free in various locations including fire departments and other areas where data shows overdoses happen frequently.

Preliminary CDC data shows that reported overdose deaths in Michigan fell 19.7% from 2023 to 2024. Similarly, Kentucky experienced a 17.7% decrease and California’s count went down 7.6% during the same time period.

“Expansion of naloxone and medications for opioid use disorder—these strategies worked,” Nora Volkow, director of the National Institute on Drug Abuse (NIDA), told NPR.

In Ohio, a decrease in the state’s supply of fentanyl seems to be the main cause behind the drop in overdose deaths, according to Harm Reduction Ohio. Ohio’s overdose deaths linked to fentanyl fell from 80% between 2020 and 2023 to nearly 70% in 2024, which is the lowest level in eight years, according to the nonprofit.

 during Covid-19 lockdowns and the subsequent social isolation period, so the pandemic ending could help explain the drop in deaths, experts told NPR.

Even if it is too soon to celebrate, some experts say that the drop in overdose deaths seen across the US is significant.

 from Opioid Data Lab—a research program created in a collaboration between the University of North Carolina at Chapel Hill, the University of Kentucky, and the University of Florida—researchers wrote that NIDA had spent $343.7 million on research to show overdose deaths could be reduced by 9% in four states in one year through measures such as overdose education and increased naloxone access.

Seeing a 12.2% decrease across the entire country in a single year, the researchers said, is notable progress.

“A reduction of this magnitude across the entire country translates to a very strong acting force,” the researchers wrote in the post. “Something has changed. And that this is happening without central coordination is a big deal. It has major implications for the way we think about overdose prevention interventions.”

A white box with pink writing indicating it holds narcan nasal spray.