Thread by @funchefchick

#WAOpioidTrial Day 15 has just begun. In a confusing twist, yesterday's trial stream started on the channel about 15 mins before court started. So we NOW join today's trial in progress at THIS link, below. McKesson continuing cross with DEA's Carter.

"Has DEA ever publicly stated the appropriate amount of medically-necessary opioids needed for the nation, or for WA?"

Well no - I'm not a medical doctor. I couldn't make that calculation.

CORRECT.

McKesson's counsel is asking Carter about earlier trial depo transcript - DEA regs changed 'drastically' in 2006-2007, so that instead of distributors notifying DEA of suspicious orders AND still shipping them, they should hold those orders. That was standard prior to 2006-2007.

That's how it was for 35 years, until 2007. So basically ANY and ALL testimony criticizing the distributors for 'continuing to ship suspicious orders' - seems totally inappropriate. McKesson pulled up an earlier trial record from someone at DEA stating this VERY clearly.

Also - Judge Scott is a huge fan of efficiency. Carter keeps asking to repeat the defense's questions, and answers in long expositional paragraphs rather than yes/no, and is a wee bit argumentative.

Wondering how frustrated the judge might be. 😬

Huh. Carter said that the person who stated in the earlier trial that 'holding suspicious orders was a new thing' in 2007 didn't know what he was talking about.

So then defense pulled up a transcript with that guy's boss, who said the same exact thing and confirmed it. Derp.

Oooh. So we heard about the "Masters Decision" earlier - DC Circuit court ruled in 2017 about suspicious orders and 'common sense rule'; in Masters an earlier decision is eluded to; the "Southwood" decision - which - FIRST introduced the 'hold, don't ship' rule - in 2007.

Basically it is still more evidence that prior to 2007, it was common practice for distributors to notify DEA when they thought an order was suspicious - BUT STILL SHIPPED IT out to the pharmacy which ordered it. Only *after* 2007 were they required to HOLD those orders.

Was that maybe because even if SOME of those orders might maybe be diverted - SOME of those orders were for real people with real pain, and suspending a pharmacy's entire order of pain meds HURTS REAL PEOPLE who did nothing wrong, and leaves them horked? Grrr.

Still more official DEA statements, rules, etc which confirm that 'hold' was not a DEA requirement prior to 2007. And that all 3 defendants in this trial had SOMS in place to block all suspicious orders by 2008.

Soo. Any time we spent on stuff prior to 2007? Zzzz.

In fact, we spent A TON OF TIME on "Period 1", or predefined eras the state introduced - which was pre-May 2007 for McKesson. Period 2 was May 2007-May 2008, right when DEA rules were changing.

LOLZ "This slide you created said there was only monthly reporting to DEA; isn't it true there was also daily reports to the DEA? As we showed you in your pre-trial deposition?"

Well it's not that this slide is inaccurate, I just didn't include that in this slide.

Wait, what?

"Here's a whole bunch of stuff illustrating the daily reports, & what was in them, which got sent to DEA which you omitted from your slide. Which you knew about, correct?"

Yes I knew this existed in the policy. I didn't put them in the slide which said 'only monthly reporting'.

"Your slide said no suspicious orders were reported, but here's a document which proves there was a specific conversation with DEA about the specific pharmacy you mentioned in your earlier testimony."

Didn't count. According to my definition.

Whaaaa?

"Here's the corp manual which says prior to 2008 any suspicious orders will be blocked. Here's prior testimony from a trial where a McKesson rep stated clearly that orders were blocked. Isn't it true McKesson required people to stop/block suspicious orders?"

I've seen no proof.

Former DEA/state's witness Carter finally said on cross: that slide I made (state's evidence, TYVM) isn't EVERYTHING McKesson did; it's a few things which were my talking points.

Umm. That is NOT how it was portrayed by state.

"Do you know one way or the other, before 2008, if McKesson blocked orders their employees were thought to be suspicious?"

I don't know. I haven't seen any evidence of it.

"You didn't see the evidence I just showed the court <lists>?"

Meh. I don't know one way or the other.🤔

And while we're on the mid-morning break - state (and DEA's) point is that distributors were 'flooding' the region with C2s.

Like it or not .. the medical profession ramped up prescribing of C2s during that period. It's just what happened. Distributors could not halt that.🤷🏽‍♀️

Aaand we're back.

"Here's a whole bunch of stuff you omitted from your slides earlier, right?"

I guess.

"Things change fundamentally over this period, yes?"

I wasn't asked about that.

You guys. It just might be that the DEA is *somewhat biased* in their retroactive interpretation of the facts regarding pain medicine, the ordering and distribution thereof.

JUST MAYBE.

Random math nerds unite: in which McKesson's counsel introduces the "Tukey Box Plot method" of numerical modeling. Which they used to assess risk/predict diversion . . . and seems super smartypants.

app.myeducator.com/reader/web/158…

Lots more of "none of this stuff - regulatory stuff - McKesson did was mentioned in any of your slides, correct?"

My slides were not meant to be conclusive. It was a few talking points I created.

Um. INACCURATE talking points, it seems.

We just went ON and ON with McKesson's counsel pointing out inconsistencies in testimony, showing evidence of compliance with DEA over the years, etc. etc.

I'm biased. Totally admit it. But I don't think the witness is holding up well on cross. And her earlier statements ..?

Anyway court is adjourned for the lunch break until 1:30, when we'll have a new link.

I've gotta step out this afternoon so I'll miss most of the afternoon. Something tells me we're going to still be on cross with this witness, so .. . I'm good with that. :)

#WAOpioidTrial Day 15 continues this afternoon at this link. I'm here for the next 20-30 mins and then . .. you're on your own. !

McKesson's counsel, on cross of state's witness Ruth Carter:

"Do you remember how much time they (DEA) spent with the McKesson people?"

Carter: Um, unless it is listed in here <gestures to transcript>, I don't. If it is listed in here, I don't recall.

I think you meant NO.?

This would be an example of the thing I said above about Carter dragging out the trial time. Like 90% of her answers on cross are not yes/no, they are - meandering statement, repeat the question, a bit combative or evasive ... this is likely driving people nuts.

McKesson's counsel points out that there are no current CFR rules or the CSA which requires any particular duration of records retention regarding distributors/controlled substances.

Carter dragged them earlier for "not retaining records for the life of the licensee". 🤔

Literally there is a new proposed rule as of LAST YEAR (2020) about document retention in the CFR: but it has not been voted on/passed yet.

Sooo. Any of Carter's statements on record-keeping 'not conducive to effective diversion control' - are her opinions. No regs exist. 🤷🏽‍♀️🤦🏽‍♀️

"You said threshold increases were commonplace, correct? Do you know what percentage of licensees in WA got threshold increases over time? Or NEVER got them?"

No, I didn't check that.

Counsel implies 70% of pharmacies NEVER requested threshold increases in WA, over 10+ years.🤯

One pharmacy in Mountlake Terrace specifically requested a temporary threshold increase to service the needs of a particular hospice patient near end-of-life who needed lots of morphine to make them comfortable. It was urgent, and serious.

Was this a red flag request? Dunno.

"If this one pharmacy had an increase of their controlled orders which in raw numbers puts them above average - but their ratio of controlled to uncontrolled was still BELOW average - this meant the pharmacy was growing overall, so C2s were not a concern, right?"

Carter: What?

Answer: Yes. All of that pharmacy's orders were growing in number. Their ratio of controlled to uncontrolled substances remained lower than average.

Sigh. Maths are hard.

Quick before I head out - last thing Carter was asked by state was whether DEA ever saw licensees/defendants refer to WA's prescribing guidelines, standard of care, etc. Carter said categorically NO.

https://twitter.com/funchefchick/status/1470841849614979073?s=20

So naturally, McKesson's counsel is introducing records showing that pharmacies ABSOLUTELY referenced WA's prescribing guidelines in their due diligence when documenting threshold requests and orders.

Whoops.

Okay, I'm out! Someone weigh in if anything exciting happens in the last hour and change today, please!

Circle back tomorrow for the last day of trial scheduled THIS CALENDAR YEAR. !