With more attention on the impact of opioid addiction and the role of overprescribing, drug companies have come under more scrutiny for suspicious and sometimes unsavory marketing practices.

A lot of the spotlight has been directed toward Purdue Pharma, the makers of OxyContin. A company that already paid $20 million in a settlement with 27 states, attorneys general across the country many years ago.

Unsealed court documents indicate that the drug manufacturer went to great lengths to stop preauthorization of OxyContin in West Virginia despite concerns from public health officials.

The warning signs of what would become a deadly opioid epidemic emerged in early 2001. That’s when officials of the state employee health plan in West Virginia noticed a surge in deaths attributed to oxycodone, the active ingredient in the painkiller OxyContin.

They quickly decided to do something about it: OxyContin prescriptions would require prior authorization. It was a way to ensure that only people who genuinely needed the painkiller could get it and that people abusing opioids could not.

But an investigation by STAT claims that Purdue Pharma, the manufacturer of OxyContin, thwarted the state’s plan by paying a middleman, known as a pharmacy benefits manager, to prevent insurers from limiting prescriptions of the drug. The financial quid pro quo between the painkiller maker and the pharmacy benefits manager, Merck Medco, came to light in West Virginia court records unsealed by a state judge at the request of STAT, and in interviews with people familiar with the arrangement.

The strategy to pay Merck Medco extended to other big pharmacy benefit managers and to many other states, according to a former Purdue official responsible for ensuring favorable treatment for OxyContin. The payments were in the form of “rebates” paid by Purdue to the companies. In return, the pharmacy benefit managers agreed to make the drug available without prior authorization and with low copayments.

“That was a national contract,” Bernadette Katsur, the former Purdue official, who negotiated contracts with pharmacy benefit managers, said in an interview. “We would negotiate a certain rebate percentage for keeping it on a certain tier related to copay or whether it has prior authorization. We like to keep prior authorization off of any drug.”

Katsur said prior authorization programs do little to eliminate inappropriate prescribing by “bad doctors” and usually just create needless paperwork for doctors working in the best interest of patients. She said some doctors simply won’t deal with the hassle of a prior authorization program, resulting in some legitimate patients not getting the medication they need.

“You don’t want to make it harder for a doctor to prescribe when they are doing the right thing,” she said.

In addition to keeping OxyContin from being subject to prior authorization, the rebates paid to pharmacy benefit managers were used to guarantee favorable status for OxyContin on their listings of approved drugs, Kastur said. PBMs commonly place drugs in different tiers on these lists, called formularies. Some tiers are more restrictive and require higher copayments. Purdue wanted OxyContin placed in the least restrictive tier – and succeeded.

The relationship with Merck Medco was so important that Purdue moved Katsur to New Jersey so she could be close to Merck’s national headquarters, she said.

It is common for drug companies to pay rebates to gain preferential treatment from companies hired by insurance plans to manage prescription drug benefits, but in this case the arrangement removed a key safeguard in the system that may have slowed the growth of OxyContin as it became a national bestseller that eventually peaked at annual sales of $3 billion.

The former Merck Medco was purchased by Express Scripts in 2012. A spokesman for Express Scripts said no one currently at the company had knowledge of the West Virginia contract. A spokesman for Purdue Pharma said the company had no comment.

In McDowell County, where the court records from a state lawsuit against Purdue were unsealed, the local sheriff said prescription pill abuse is so rampant that the county plans to file a new lawsuit against painkiller makers.

A new study published in the American Journal of Epidemiology and summarized in Ruters Health says that regular use of pain relievers over many years may increase the risk of hearing loss.

Researchers analyzed long-term data on almost 56,000 U.S. women and found using non-steroidal anti-inflammatories (NSAIDS) like naproxen (Aleve) and ibuprofen (Motrin) as well as acetaminophen (Tylenol) for six years or more was tied to a greater risk of hearing problems than taking these drugs for a year or less.

“Hearing loss is extremely common in the United States and can have a profound impact on quality of life,” said senior study author Dr. Gary Curhan, a researcher at Harvard University and Brigham and Women’s Hospital in Boston.

Risks of the painkillers in the study go beyond hearing loss and patients should do their best to avoid long-term use, Curhan added by email.

“Even though these medications are sold without requiring a prescription, they do have potential side effects, one of which is a higher risk of hearing loss; they have also been shown to be associated with a higher risk of hypertension (high blood pressure) and other important medical conditions,” Curhan said.

“They are generally safe when taken in usual doses for short periods of time,” Curhan noted. “However, there should be strong justification for long-term use.”

Women in the study who used NSAIDs at least twice a week for six years or more were 10 percent more likely to report hearing loss than participants who used these drugs for less than one year.

With acetaminophen, regular users for at least six years were 9 percent more likely to report defective hearing than short-term users, researchers report in the American Journal of Epidemiology.

Researchers did not find a statistically meaningful association between hearing loss and the duration of aspirin use.

Aspirin has been linked to ringing in the ears in the past, and Vicodin, a painkiller that contains acetaminophen, has been tied to hearing loss with overuse, noted Dr. Jennifer Derebery of the House Ear Clinic and the University of California, Los Angeles.

Ibuprofen is less commonly recognized by the public as a potential cause of hearing damage, Derebery, who wasn’t involved in the study, said by email.

Previous research has found a similar link between painkillers and hearing loss in men, though studies to date have yet to explain how the drugs might impact hearing, said Dr. Wilko Grolman, a researcher at the University of Utrecht in the Netherlands who wasn’t involved in the study.

However, the study is observational and doesn’t prove these painkillers cause hearing impairment.

“The hearing loss was self-reported and not measured objectively with hearing tests,” Dr. David Haynes, a researcher at Vanderbilt University Medical Center in Nashville who wasn’t involved in the study, said by email.

A drug distributor owned by Cardinal Health Inc has agreed to pay $10 million to resolve claims it failed to alert the U.S. Drug Enforcement Administration to suspiciously large orders of addictive painkillers by New York-area pharmacies.

The settlement with Kinray LLC, a New York City-based pharmaceutical distributor, disclosed in papers filed late Thursday in federal court in Manhattan, comes amid efforts by U.S. authorities to combat the nation’s opioid drug epidemic.

The settlement was secured by the office of Preet Bharara, the U.S. Attorney for the Southern District of New York, who has increasingly turned his sights toward the growing opioid drug epidemic.

The Kinray settlement came after a DEA investigation of pharmacies in New York and elsewhere that had ordered unusually large and frequent shipments of oxycodone or hydrocodone, according to a lawsuit filed earlier this week.

From January 2011 and May 2012, Kinray shipped the drugs to more than 20 New York pharmacy locations in amounts that were many times greater than the distributor’s average sales of controlled substances to all of its customers, the lawsuit said.

Kinray ignored numerous “red flags” and did not report any suspicious orders to the DEA despite requirements that it do so for such highly regulated drugs, the lawsuit said.

The latest agreement stemmed from a 2012 settlement with the DEA in which its facility in Lakeland, Florida, was suspended from selling painkillers and other drugs for two years, according to Cardinal.

The 2012 deal only resolved administrative aspects of the case, not potential fines Cardinal Health faced in Florida or elsewhere. The Dublin, Ohio-based company has set aside $44 million to cover those potential liabilities.

Cardinal Health, which announced its $1.3 billion acquisition of Kinray in 2010, said on Friday it continues to work with the U.S. Justice Department to resolve the matter.

As part of the settlement, Kinray admitted and accepted responsibility for failing to report suspicious orders to the DEA, according to court papers.

The case is U.S. v. Kinray LLC, U.S. District Court, Southern District of New York, No. 16-cv-09767.

Allstate went before a judge and jury to put an end to the illegal ownership, kickbacks and fraudulent operation of multiple law offices in the Los Angeles area that were owned, operated and controlled by unlicensed people posing as lawyers.

The verdict in a Los Angeles County Superior Court resulted in a judgment worth more than $11.5 million in favor of Allstate.

“Submitting even one false insurance claim is fraud and insurance fraud is a crime,” says Allstate’s Senior Field Vice President Phil Telgenhoff. “Fraud drives up the cost we all pay for insurance by stealing millions of dollars from insurers. This cannot and will not be tolerated in California or anywhere.”

Allstate alleged Christina Chang, Christine Suh and other unlicensed persons knowingly engaged in a fraud scheme in which they used the identity of practicing lawyers to create eight phony or “sham” law offices to make false, fraudulent or misleading claims against insurance companies so that settlement payments could be converted to their own use.

Evidence presented at trial showed that several California lawyers were paid $3,000 per month for the use of their names and law licenses. None of the licensed lawyers had significant direction or control over the operation of the fake law offices or the making and processing of claims.

Chang and Suh rented office space, hired staff, opened firm bank accounts, obtained clients, made demands to insurance companies for settlement and negotiated settlements, all in the name of licensed California attorneys, falsely making it appear as if a lawyer represented the client and claimant.

The evidence also showed Chang and Suh used remote check-cashing facilities including liquor stores and small local markets to convert the settlement proceeds into untraceable cash from deposits into client-trust accounts.

Allstate contended Chang and Suh knowingly concealed the fact that the law offices were owned, operated and controlled by unlicensed persons, all in violation of California’s Insurance Frauds Prevention Act.

“This is one of the first times I’ve seen this elaborate of an effort with setting up fake law offices and trying to defraud the industry,” says Telgenhoff. “We have seen this type of operation before with shady medical clinics across the country, but this takes the scam to a different level. Rest assured, we will fight fraud wherever it lives.”

Several new laws affect workplace safety, including a package of bills that took effect June 9, 2016.

AB 1785 reaffirms the general ban on using wireless electronic devices while driving, but amends existing law to authorize drivers to use their hand to activate or deactivate a feature or function of the device with a single swipe or tap, as long as the device is mounted so as not to hinder the driver’s view of the road.

Despite the steady expansion of legislative prohibitions on the use of wireless telephones and electronic wireless communications devices while driving, and the clear dangers of distracted driving, in 2014, the California Court of Appeals for the 5th District ruled that the existing ban only prohibits a driver from holding a wireless telephone while conversing on it. In making its ruling, the court found that the legislative intent in enacting those prohibitions was merely focused on prohibiting a wireless telephone only while carrying on a conversation, not while using it for any other purpose. For that reason, law enforcement agencies find it difficult, if not practicably impossible to enforce the prohibition, as the scope of a mobile device’s functions and its contributions to distracted driving go far beyond simply making and receiving telephone calls.

The new law bans all handheld use of wireless electronic communication devices by the driver of a vehicle during its operation, without reference to the purpose of that use. An exception is provided for windshield-, dashboard-, and center console-mounted devices when the driver can activate or deactivate the feature or function he or she is using with a single swipe or tap and the placement of the mounted device does not hinder the driver’s view of the road. As such, drivers can still engage with their phones in the relatively simple ways that are most similar to other sources of distraction that society has long accepted, such as changing the channel on a car radio.

Four bills (SB-5, SB-7 and AB-5, AB-7) were signed earlier this year that extend the ban on workplace smoking. These rules took effect June 9, 2016.

Specifically AB 7 removes many (but not all) exemptions in existing law that allow tobacco smoking in certain indoor workplaces and expands the prohibition on smoking in a place of employment to include owner-operated businesses. It establishes “smoke-free laws,” which prohibit the smoking of tobacco products in various places, including, but not limited to, school campuses, public buildings, places of employment, apartment buildings, day care facilities, retail food facilities, health facilities, and vehicles when minors are present.

AB 7 prohibits employers from knowingly or intentionally permitting the smoking of tobacco products in an enclosed space at a place of employment. It defines “enclosed space” as including lobbies, lounges, waiting areas, elevators, stairwells, and restrooms that are a structural part of the building and not specifically exempt. It extends the workplace smoking prohibition to include owner-operated businesses in which the owner-operator is the only worker and there are no employees, independent contractors, or volunteers. There are no exemptions for employers of any size.

SB 1167 requires Cal/OSHA to propose a heat-illness and injury prevention standard for indoor workers by Jan. 1, 2019. SB 1167 does not specify what provisions will be included in the new rule or what types of workplaces will be covered – potentially, the new rule could include all indoor workplaces. The law is a result of litigation on this issue.

A recent Occupational Safety and Health Appeals Board (Appeals Board) decision affirms the responsibility of employers to ensure indoor heat illness is addressed through their IIPP. The case stemmed from a 2012 serious citation issued to Tri-State Staffing and warehouse operator National Distribution Center for the heat illness suffered by an employee who was working inside a metal freight container with a temperature of over 100 degrees. DOSH penalized both companies for failing to implement an effective IIPP and both companies appealed the citation winning their case before an administrative law judge (ALJ).

In March 2015, DOSH appealed that decision to the Appeals Board stating that the employers had failed to effectively correct the indoor hazard and had not trained employees on indoor heat exposure. In November 2015, the ALJ’s decision was overturned by the Appeals Board reinforcing the responsibility that employers have to protect the health and safety of their workers, including those working indoors.