Pharmacy Benefit Manager Involvement in the US Opioid Crisis.

Importance: The opioid crisis in the US has been attributed in part to the pharmaceutical industry's inappropriate marketing of opioid medications. How pharmaceutical companies work with pharmacy benefit managers (PBMs) to increase opioid dispensing has not been studied. Objective: To examine the potential role of PBMs and pharmaceutical companies in the opioid crisis. Design and Setting: A qualitative study using retrospective data was conducted of opioid industry documents released in litigation that have been collected and preserved digitally at the University of California, San Francisco, and Johns Hopkins University Opioid Industry Documents Archive. Data collection was conducted from January to April 2026, with iterative keyword searches. Documents were identified in searches chronologically, then results were categorized by theme. Main Outcomes and Measures: Research of pharmaceutical industry documents to assess professional and financial relationships between PBMs and opioid manufacturers. Results: This study of 23 pharmaceutical industry documents dated from 1997 to 2018 identified 3 major themes in the coordinated activities of opioid manufacturers and PBMs: (1) both manufacturers and PBMs encouraged health care professionals to increase opioid prescribing, (2) PBMs expanded the allowed doses and durations of opioid prescriptions, and (3) opioid manufacturers paid PBMs when dispensing of branded opioids increased. Conclusions and Relevance: These findings suggest that PBMs and opioid manufacturers had undisclosed financial relationships that may have exacerbated the opioid crisis. Regulatory restrictions on these relationships, including the elimination of rebates, could increase transparency and reduce the risks of public health harm due to misuse of addictive medications.