Thread by @HesslerHD

I’m back for day #34 of the #opioidtrial in Charleston. After resting its months-long case Huntington and Cabell County faced their biggest obstacle Thursday — satisfying an inquisitive judge. herald-dispatch.com/news/cabell-co…

McKesson attorney Paul Schmidt calls to the stand Dr. Christopher Gilligan, Chief of the Division of Pain Medicine at Brigham and Women’s Hospital.

He was asked how pain impacts a patient.

“Not only do they have suffering from the pain, but we have their life being taken away from them by the pain,” he said.

We are reviewing the report "Relieving Pain in America", which was funded by the Institute of Medicine ncbi.nlm.nih.gov/books/NBK91497/

The report said "A reasonable degree of access to pain medication—such as the stepped approach of the WHO Pain Relief Ladder for cancer—has been considered a human right under international law since the 1961 adoption of the U.N. Single Convention on Narcotic Drugs"

He said there are several treatment options - like physical therapy or acupuncture -- to try before opioids. He said sometimes his patients try them all to no avail. They have no choice but to look to treatment with opioids and other medications to help.

He said they lay out the risk and benefits of such prescriptions to determine how high risk the patient is for getting opioid use disorder. They also look at how well the other treatment options work.

We are looking at a warning label/tag for Percocet (Oxycodone and Acetaminophen Tablets), which warns of addiction, abuse, Neonatal opioid withdraw syndrome, and misuse. It also alerts doctors to assess a patient's risk of OUD.

Gilligan said he takes these warnings very seriously when he is making a decision on whether or not to prescribe opioids.

“It boils down to, largely, risk versus benefits,” he said.

Some things they look at to determine risk of OUD is the patient's mental and family history.

He said it's rare in his patients that he sees people he has prescribed opioids move to heroin. Now we are looking at "Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States"

samhsa.gov/data/sites/def…

It said from 2002 through 2011, a study found that the recent heroin initiation rate was 19 times higher among those who reported prior nonmedical pain reliever use than among those who did not (0.39 vs. 0.02 percent).

Within the study, it showed in the 12-49 age group, only 1.1% of people using heroin had no prior history of abusing medical pain medicine or illicit drugs. Schmidt said this shows 98.9% people using prescription opioids do not acquire opioid use disorder.

This study was published in 2013, FWIW, and uses data from 2002 to 2011.

He said other countries are much more conservative with opioid prescribing than in the US. He works with hospitals in China and see patients there who's quality of life would dramatic increase if they could be prescribed opioids.

Doctors are bound legally to their patients' actions. Doctors are heavily scrutinized on their opioid prescribing and face consequences if they make the wrong choice.

He said the standard of care for opioid prescribing has changed over the decades. In the 80s and 90s there was an emphasis they were under prescribing and under treating pain. Around 2000 the thought was they were prescribing too many. Prescribing peaked around 2010.

He say today, opioids are still utilized in the medical community, but doctors are much more conservative with their prescribing.

Essentially Gilligan's testimony surrounds the gravity doctors have to use when determining whether opioids should be prescribed.

Said docs have to weigh risks & benefits of opioid prescribing, while trying to satisfy ever-changing policies of regulators & medical board, who set prescribing standards. Asked if the distributors had a say in patients' treatment or physicians' prescribing methods, he said no.

Schmidt has been going over several polices, etc, which show around 2000 the Joint Commission, West Virginia Board of Medicine and other groups started shifting standards and asking doctors to treat pain as the fifth vital sign.

Gilligan said prescribers took as a sign they were under prescribing opioids and needed to take pain complaints more seriously. Prescribing peaked around 2010, as the opioid epidemic started to burn.

In 2010, West Virginia doctors were told they should not fear possible investigations if they were treating legitimate pain, one document said.

We are done for the morning and will return at 1:30 p.m. for cross examination.

We are back and the defense just said they think they will just need three more weeks to present their case! They had been allocated 6+. 🎉🥳🍾🎁🥳

A majority of the testimony has just been Gilligan reading things sentences and paragraphs into the record. I wish we could hear more from Gilligan about his experience and knowledge of opioid prescribing, instead.

Paul T. Farrell Jr. is about to cross examine Gilligan.

Cabell County Paul T. Farrell attorney pointed to a study (McCabe?) which said the vast majority of prescription opioids users do not move to heroin, the reverse happens.

Farrell said it shows the number of people who used heroin first was 1%, but 80%, four out of five, had used prescription pills before moving to heroin, a statement with which Gilligan agreed.

The study is "Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States", if you want to look at it. samhsa.gov/data/sites/def…

Another article said "Nearly 1 in 3 adolescents in recent studies who reported nonmedical prescription opioid misuse transitioned to any heroin use." pubmed.ncbi.nlm.nih.gov/32991383/

Gilligan agreed with Farrell that a large number of medicines being sent to an area would lead to misuse and diversion, which would lead to people using heroin.

His testimony is affirming the gateway theory between prescription pills and heroin.

“I think there is a direct relationship that includes the misuse (of prescription pills), along with many other factors, that does relate to the use of heroin,” he said.

Farrell pulled out one of Gilligan's old presentations in which show as sales and doctor prescribing over overdoses increased, so did overdose death numbers and treatment admission.

The presentation also used a Centers for Disease Control article which said for every one opioid-related earth there are 825 non-medical users out there.

Now we are looking at this talk he gave at a Seattle Science Foundation event

In this presentation, Gilligan said 80% of people taking heroin started with prescription opioid use. The reason for the ship was heroin became cheaper and more accessible.

Now we are looking at Opioid Abuse in Chronic Pain — Misconceptions and Mitigation Strategies nejm.org/doi/pdf/10.105…

"However, two major facts can no longer be questioned. First, opioid analgesics are widely diverted and improperly used, and the widespread use of the drugs has resulted in a national epidemic of opioid overdose deaths and addictions."

Gilligan said that is just one part. It's not a complete statement. He thinks misuse and abuse of prescription medication attributed to it, but there were many other factors that factor in.

"Second, the major source of diverted opioids is
physician prescriptions," the article continued.

Gilligan said the major source is people who receive them and give them to friends and pills. The pills are being diverted, nonetheless.

Huntington attorney David Ackerman pointed to reports which said the effectiveness of opioids as pain relievers, especially over long term is unclear and often times do not treat pain, it just masks it.

Ackerman pointed to another article which said. structured review of 67 studies showed 3% of chronic noncancer pain patients regularly taking opioids developed opioid abuse, while 12 % developed aberrant drug related behavior. ......

Half of patients who received prescriptions for 2009 had filled another opioid prescription within the previous 30 days, it continued.

Ackerman is done. Time for redirect.

Gilligan is finished with his testimony and has been excused from the stand. The day is over. Working on story now.

FINAL STORY: Distributors accused of fueling the opioid crisis presented their 1st witness at a months-long trial Friday, a pain doctor whose testimony in effect strengthened the theory of there being a gateway between prescription opiates and heroin use. herald-dispatch.com/news/doctor-te…