Thread by @HesslerHD

I’m back for day 35 of the #opioidtrial in Charleston. The defense is continuing to present its witnesses today. Get caught up on what happened last week here: herald-dispatch.com/news/dismissal…

First up is Dr. Timothy Ray Deer, a pain specialist in the Charleston area. wvexecutive.com/timothy-deer-m…

Deer runs one of the largest pain clinics in the state, The Spine & Nerve Centers, which has about 4,000 patients at any given time. He has been on WV task forces, such as the WV Controlled Substances Monitoring Program Committee, which was established in 2012.

Deer has worked on several West Virginia task forces and helped write prescribing guidelines, which include work with the Controlled Substance Monitoring Program Committee (2012), Safe and effective management of pain guidelines (2016) .....

.....and the Coalition for responsible chronic pain management (2017-2020).

He said the guidelines and committees are needed because overtime, standard of care changes and doctors have to change with it.

For this case, Deer was asked to look at the standard of care in West Virginia and look at how opioid prescribing evolved over time. This includes looking at how laws and society changed and how doctors' behavior changed from 1994 to 2021.

He said there have been 3 main phases of opioid prescribing during that time:

- mid 90s-2010: liberalization of prescribing opioids
- 2010-2015: balancing
- 2015-present: conservative

The trends were national, but evident in WV. WV demographics played a role in it, as well.

He said during the 1st phase, he accepted the notion pain was being undertreated & went along with the flow of those pushing for more opioid prescriptions. However, @ some point he scaled it back when he started to bump heads w/ the same people pushing for more prescribing.

He said during the second phase, they started seeing more discussion of the problem and doctors, like himself, pushing back, which led to laws and programs to better monitor prescribing, such as requiring pain clinics to register as such.

Today, his practice is conservative in its prescribing and looks at alternative therapy to help patients. Oftentimes patients are referred to him after being on opioids for years because of doctors who do not know how to treat pain otherwise.

He said every doctor is required to follow the standard of care -- ethical guidelines stating what a responsible doctor would do in that situation -- and could face consequences if they do not.

The standards evolve over time. For example, one of those standards had been looking at pain as the fifth vital sign

"Pain as the fifth vital sign" started around the turn of the century and was removed from the American Medical Association standards in 2016.

He said during this time it was standard for a person to not even be discharged from the hospital if they were still in pain, which led to more opioid prescribing.

Before the turn of the century doctors only prescribed small doses of pain pills because they were in fear of losing their licenses, he said. In 1997, the WV Board of Medicine issued guidelines on opioid prescribing to ease those fears. He said it followed national trends.

During that same era, doctors were told/under the understanding that upping the dosage amount was the answer to treating pain, not looking at alternative options, like physical therapy, etc.

The Intractable Pain Act was passed by the WV Legislature in 1998 to protect doctors prescribing opioids to patients with severe chronic pain. It allowed physicians to prescribe high doses of opioids for long terms w/out repercussions, as long as they had evidence it was needed.

In 2001, West Virginia Boards of examiners for registered professional nurses, medicine, osteopathy and pharmacy issued a joint policy for pain management at the end of life.

It said pain should be treated & health professionals should recognize tolerance and physical dependency are normal consequences of opioid use, but not synonymous with addiction. Government policies should not interfere with prescribing standards during end of life care, it said.

In 2005, the West Virginia Board of Medicine issued a policy for the use of controlled substances for the treatment of pain, which said the inappropriate treatment of paint included non-, under- and overtreatment of pain.

Doctors sometimes feared an investigation for not prescribing opioids, he said.

Deer said these policies were common across the country and not just happening in West Virginia. The policies had a big impact on physician prescribing, he said.

In January 2005, 35 attorneys general, including then-W.Va AG Darrell McGraw, sent a letter to the DEA, to express concern about DEA policy changes which targeted the overprescribing of opioids. Here's a look at that letter amednews.com/article/200502…

The policy was updated in 2009 to make it easier to treat pain patients who did not have severe, chronic pain.

https://twitter.com/HesslerHD/status/1412784843478515720?s=20

The joint policy was re-adopted in 2010.

https://twitter.com/HesslerHD/status/1412786478577504257?s=20

Cardinal Health attorney Enu Mainigi is using a bar graph showing opioid distribution in Cabell County over a couple decades, plotting dots to represent each time a policy was made.

Deer said the statutes and policies' push for more prescribing was followed by the influx in the amount of pills being distributed.

Deer said West Virginians demographics had a large part in the high rate of opioids prescribing, pointing to four specific things: a high rate of chronic pain, older population, more injuries with more workers in physically demanding jobs and insurance policies.

He said WV is on average 4 years older than the average nationally. The state has a blue collar workforce with high injury rates, he said.

He said many times insurance policies don't cover innovative therapy, especially West Virginia Medicaid, which led to an influx, as well.

The West Virginia Uniform Controlled Substance Act was passed in 2012 requiring doctors to monitor a patient’s history to cut back on doctor shopping throughout the state and put restrictions on pain clinics. It allowed physicians' opioid prescribing to be more closely monitored.

The act did not limit the amount of opioids which could be prescribed, however. Deer said this was the moment opioid prescribing went down and, thus, the amount of pills being shipped to the area.

Around 2014, the CDC also issued guidelines for prescribing opioids, telling doctors to look at alternative methods of pain treatment. Deer said the turn caused less doctors prescribing opioids for long-term, years-long pain. The amount of pills shipped continued to drop

he West Virginia Opioid Reduction Act was passed in 2018 to further encourage conservative opioid prescribing. oig.hhs.gov/oas/reports/re…

“Hopefully we will continue to evolve for the better and continue to make progress,” Deer said.

We will return at 2 p.m. for cross examination of Deer.

During break I've tried to go back to see if one party in the W.Va legislature was responsible for these opioid guidelines. What I've learned: I will never be a good fit to be a statehouse reporter.

The Intractable Pain act, which had bi-partisan support, was passed in 1998 by the WV Legislature in 1998 to protect doctors prescribing opioids to patients with severe chronic pain.

The statue was updated in 2009 to make it easier to treat patients who did not have severe, chronic pain. Six democrats -- including Wayne Del. Don Perdue and majority leader Brent Boggs, sponsored the bill, with one, minority whip Larry Border, as the lone republican.

The West Virginia Uniform Controlled Substance Act -- sponsored by Senate president Jeffrey Kessler and Sen. Daniel Hall, both democrats at the time, passed in 2012 requiring doctors to monitor a patient’s history to cut back on doctor shopping & put restrictions on pain clinics

The West Virginia Opioid Reduction Act, sponsored by by senate leaders Republican Mitch Carmichael and Democrat Roman Prezioso, was passed in 2018 to further encourage conservative opioid prescribing.

We are back with attorney Bob Fitzsimmons, wo asked Deer if he believes there is an ongoing opioid epidemic in the area. Deer said he believes there was a change in the standard of care.

He said there were a lot of pills prescribed in West Virginia and that was a cause of the epidemic and the volume was a cause of the epidemic. He said in retrospect there was extensive prescribing.

"I think it has evolved into non-prescribed drugs, (...) but there's still a crisis nonetheless," Deer said, later adding "It's changed overtime, but there's still an opioid problem in WV."

Fitzsimmons said the shift to heroin and illicit drugs did not begin until the number of pills being shipped was reduced starting in 2011-2012.

Fitzsimmons said over 65% of the opioids in the state come from primary care physicians, not pain management specialists like Deer.

Deer said the material to which he testified was put together by Cardinal Health and things he felt would fill in the gaps. Fitzsimmons asked if he ever received the volume of pills being prescribed and shipped by CH into the counties or any related data. He said no.

Fitzsimmons asked if he knew how many doctors had been busted for bad prescribing. He only remembers Philip Fisher, who is currently serving a federal sentence in a murder for hire plot.

Deer doesn't know the number of people living with substance use disorder are living in the county. He said he did not review, or ask for, any data in the case before his testimony.

There's a lot of quibbling by attorneys. Fitzsimmons asked if he thought there was bad behavior by prescribers in WV.

“I think there were doctors who prescribed inappropriately,” Deer said. “There are a lot of doctors (who) misprescribed, but if you look at the percentage, it’s pretty low. One is too many in West Virginia."

Fitzsimmons said Deer had previously testified during a deposition he knew too many people had been prescribed pills by a lot of bad doctors, which they would then sell on the illicit market.

Deer previously testified "blue collar jobs", like coal mining or logging, was a factor which led to high numbers of opioid prescribing. Fitzsimmons asked him if he knew how many tons of coal had been mined or lumber cut in the county over the last two decades.

(spoiler) None.

In 2006 a paper Deer co-wrote on proper opioid prescribing said 15.1 million people had admitted to abusing prescription drugs at the time, which was fueled by dramatic increases in manufacturing and distribution of prescriptions.

Although his name is on the article, Deer said he hasn't read the entire thing or study it.

Fitzsimmons showed Deer his own prescribing rates from 1997 to 2017. He was in the top five of Kanawha County doctors for opioid prescribing. He was the second highest prescriber for hydrocodone and the first for oxycodone in the county, Fitzsimmons said.

Deer said his pain practice is the largest in the state and sees more than 4,000 patients. He said the statistic for which 98% of which were end of life care.

But Fitsimmons said even for opioid dosage units prescribed, Deers’ were triple that of other physicians during the height of opioid prescribing in the state.

Deer said the chart was a misrepresentation because he receives pain management referrals and will receive patients already on high dosages of opioids. Fitzsimmons said while the opioid prescriptions dramatically decreased below the average around 2015-2016.

He said it is because the patients he receives are on a lower dose now and they are working to get more people off of the drugs.

Deer has been excused from the stand and Dr. James Hughes has been called up by McKesson attorney Timothy Hester. He is a economist.

(I do not have room for an hour and a half more of testimony. Oh no.)

Hughes is making $950 an hour on this case. Rethinking my life, right now.

He is going to be an expert in health economics and insurance related to prescribing.

Hughes said about 93% of West Virginians had health insurance in 2018. 44% were insured through an employer, 26% on Medicaid and 19% on Medicare. He said he would expect the percentage of people on Medicaid in West Virginia in Cabell County would be well above that average.

About a quarter of Cabell Countians live below the state's poverty line, he said. In 2019, 96% of all prescriptions drugs in West Virginia were covered by insurance, he said. For opioids, he said he would expect a higher fraction would be paid by Medicaid.

Medicaid has a written policy it will only cover medically necessary health services, he said. Requiring prior authorization of treatment is how they make sure this rule is followed, he said.

He said Pharmacy Benefit Managers work as a in-between between pharmacies and insurance companies. For the patient, the physician works as the in-between between patients and insurance.

He said that insurance companies and PBM could have stopped overprescribing doctors by cutting off payments.

NGL - this might be the driest, most boring testimony I've listened to in two months of testimony.

West Virginia Medicaid has access to the Controlled Substances Monitoring program and could have been watching, he said.

There were three tools payors could use to influence prescribing behavior, Hughes said.

1. prior authorization.
2. step therapy
3. quantity limits

The payors are in control because they are who pay out claims, he said.

Step therapy calls for patients having to undergo other treatment before they are approved for a certain thing. Like having to go to physical therapy before you're approved for opioids.

He said studies have shown the utilization of these types of tools can be effective in the reduction of opioid prescriptions.

Hughes examined the PEIA and Medicaid, which insure about 40% of West Virginians and said around 2000, the two made use of the tools in ways designed to control cost, not with the patient’s risk in mind.

For example, step therapy was used in 2005, he said, but it was to encourage doctors to use off-brand opioids before moving to the more expensive name brands.
Medicaid imposed opioid quantity limits in 2009 and 2015, he said.

From 2012-16, only 40% of opioids had quantity limits for PEIA insurance. As of 2016, it was 100%. Only 10ish% had requirements for step therapy. From 2015-2020, none required step therapy. In 2020, it shot up to 40%

In 2012, 73% of opioids did not require prior authorization under PEIA. That number dropped to 13% by 2019 and as of July 1, 2020, it was 0%

Prior authorization is now needed on all opioid prescriptions under the insurance plan.

We are done for the day and will return tomorrow with the cross-examination of Hughes.

FINAL STORY: Testimony at a trial in which Huntington and Cabell County seek a remedy against distributors accused of adding fuel to the fire of the opioid crisis showed politics has played a role in the prescribing of opioids in the state for decades. herald-dispatch.com/news/politics-…