The Surprising Morality of Opioid Distribution

Sadly, it is difficult to avoid the epidemic of opioid abuse afflicting our country. While the media have helped bring attention and focus to this issue, too many people are experiencing it first-hand as they or their loved ones battle opioid addiction. It is a crisis that demands attention, action, and accountability.

The search for accountability has directed significant attention to a relatively unknown but important industry – pharmaceutical distribution. There are only a few large corporations with businesses in this space, and AmerisourceBergen, the company I lead, is one of them.

The focus on pharmaceutical distributors is born from the fact that nearly every prescription medicine available in the United States moves through distributors who purchase drugs from pharmaceutical manufacturers and sell them to pharmacies – pharmacies like a neighborhood drug store as well as those in hospitals, nursing homes, hospices and other clinical settings. We don’t manufacture these drugs, provide them directly to patients or take any action to drive their demand, but it is an undeniable fact that, as a growing number of opioid-based pain treatments were prescribed, pharmaceutical wholesalers distributed more of these medicines. We have, of course, seen the same growth as larger numbers of prescriptions were written for less controversial therapies that treat conditions like high cholesterol and blood pressure, among others.

Pharmaceutical distributors have an important role to play in addressing the opioid epidemic. Distributors must create a supply chain that is safe and secure. We must ensure our customers are licensed and registered with appropriate entities like the DEA and state boards of pharmacy. And, we need to cooperate with law enforcement to support their work to remove entities that are behaving unethically. We’ve made significant effort to do just that.

We report the quantity and details of every order of opioid-based medication we ship directly to the DEA on a daily basis. We use complex algorithms to identify and stop orders that are deemed to be suspicious. In fact, we’ve reported and stopped tens of thousands of suspicious orders since 2007, not to mention the countless other orders that pharmacies never had the opportunity to place because we declined to service them altogether. We employ teams of experts to interview and learn about our customers, and we’ve invested heavily to ensure that our facilities have the best possible protocols and technology to eliminate the diversion or theft of these controlled and highly regulated products from the minute they enter our facilities to the time they are delivered to our pharmacy customers.

But with all that said, the expansion of the opioid crisis demands the asking of a straightforward question: Why don’t distributors, like AmerisourceBergen, simply stop selling these medicines to pharmacies or set limits on the amount of these medicines that can be ordered? These are questions I ask myself regularly, and the answer hinges on the role we play in the overall supply chain for medicine.

The Food and Drug Administration approves opioid-based pain medicines based on the criteria that the drugs’ benefits outweigh their risks. Total supply of prescription opioids is determined by production quotas, which are set by the Drug Enforcement Agency (DEA). Licensed physicians write prescriptions for these drugs, which are filled by pharmacists. Pharmacies – only those registered with the DEA – place orders with distributors. Distributors fill those orders, and pharmacies and pharmacists dispense the drugs to patients.

At AmerisourceBergen, we define our purpose as having a “responsibility to create healthier futures.” We achieve our purpose in many ways, but one of the most fundamental is creating highly efficient and safe access to medications.

If AmerisourceBergen or our peers made the decision not to fill orders for these therapies, we would put ourselves in a position to interfere with individual clinical decisions that are made by health care providers with their patients. It would create an environment where logistics businesses with no access to patient- specific information would make it difficult or impossible for patients to access medicines prescribed by their physicians. Perhaps most importantly, it would set a dangerous precedent where a small number of corporations could effectively reduce or eliminate access to medication that was approved by the FDA and prescribed by a licensed physician.

The power to override clinical decisions is not an authority that should be granted to us. 

It is easy to understand why many want us to go further, and I, along with others at AmerisourceBergen, have at times wanted to divorce our company from these therapies entirely. They represent a small fraction of our business and most importantly, stepping away from these drugs entirely would be the firmest possible stance we could take to combat the tragic opioid epidemic. But, it would be a choice that is antithetical to our purpose and one that oversteps our role in healthcare.

A decision by us to stop or severely limit distribution of these drugs would mean for example that cancer patients who need to manage their pain might not be able to access approved medicines that could ease their suffering. Hospices may not have the right therapies to provide comfort to patients in their care.  And, it would mean that a corporate distributor supersedes FDA and DEA approvals and clinical decisions made by healthcare providers to meet the needs of their patients. Stopping distribution of opioids would be an easy but amoral choice for a distributor. Instead, we will work to do everything we can from our position, and with partners across the entire spectrum of healthcare, to make the availability of these drugs as safe and secure as possible.