Thread by @funchefchick

#WAOpioidTrial Day 20 is about to begin; here's the AM link for today.

SEVERAL big issues to be decided upon this morning by the Judge; who will have reviewed a few briefs from counsel this morning before court adjourns. WHAT will happen?? Stay tuned.

#WAOpioidTrial The first big question: Will the Judge allow these subjective surveys to be admitted - dancing around whether Dr. Banta-Green is a fact witness (which means the surveys COULD be hearsay) or if he's a dang expert (which he clearly is, but not for this trial?)

#WAOpioidTrial The judge - sort of bemused about how state keeps referring to Dr. Banta-Green as a 'fact witness' - has asked both parties for BRIEF oral arguments about admitting the surveys.

Hopefully defense brings up that it was a teeny survey of one county by syringe users.

#WAOpioidTrial State: "While Dr. Banta-Green is not a 'disclosed expert witness' he's clearly a super-dang-seriously-credentialed witness sooooo .... "

Um. Does state get to have it both ways?

#WAOpioidTrial Defense is really nailing the points in their oral argument: the survey data collected was NOT objective; it was incredibly subjective. The surveys were from very specific groups (syringe users, 10th graders) which do not represent the entire state, etc. etc.

#WAOpioidTrial AND. The judge has ruled that the surveys are OUT and said "I note with some irony that the witness on the stand (Dr. Banta-Green) is not considered an expert witness. Without the surveys being backed by an expert witness, these are double-hearsay." and OUT.

#WAOpioidTrial And state - tries to re-litigate the issue after the judge's ruling, and he tells state to quit it.

Aaaaand Dr. Banta-Green (NOT A DISCLOSED EXPERT WITNESS) is back on the stand via zoom. This will be interesting, as state has been told - NO expert witness Qs.

#WAOpioidTrial Um ... state is continuing to ask Dr. Banta-Green about 'his basis of knowledge about those surveys' ??

They are legit asking more expert witness questions. Still. Defense objects (obvs.)

Judge sustains again. Obvs.

????

#WAOpioidTrial Lather, rinse, repeat: more of same.

Judge gently admonishes state to quit asking questions 'without foundation' (and also eliciting hearsay).

He's a fact witness only. If you want to ask him expert witness questions ... you have to admit that he is one. 🤷🏽‍♀️

#WAOpioidTrial !!! The state just spent quite a few minutes asking Dr. Banta-Green surrounding questions to end-run around his not-an-expert-witness status - and NOW, the judge has excused the witness so that judge can further admonish the state about STOP DOING THAT ALREADY.

#WAOpioidTrial I'm no legal expert . .. but I think the state is antagonizing the judge with this. He's made a ruling, and state just keeps proceeding on ahead.The judge just ruled AGAIN that state can't ask Dr. Banta-Green expert witness questions. Again. Will state listen?

#WAOpioidTrial State's finally moved on to new topics. Dr. Banta-Green - bless him - clarified that there was medical and non-medical use among those prescribed opioids AND among those NOT prescribed. Many people take un-RX'd opioids for PAIN control, not to get high. Truth.

#WAOpioidTrial OMG. State is trying to say that because illicit drug distributors made counterfeit pills w/fentanyl it made people more 'comfortable' taking them. Now it is the pharmaceutical distributor's fault that counterfeits with fentanyl have been made?! Seriously?!! 🤯

#WAOpioidTrial Like 75% (maybe more) of the questions state asks of Dr. Banta-Green have been objected to by defense, and the objections sustained by the judge.

State has hamstrung themselves by limiting his role. But if he was an expert, defense could ASK HIM WHAT HE THINKS.

#WAOpioidTrial Because here's the facts: many people in WA (and nationwide) have died from drug poisoning, and it's been increasing for years. Dr. Banta-Green can testify to that all day.

Now ... ask him why, and if he thinks distributors are liable. Oh wait - they can't.

#WAOpioidTrial We're now looking at an ADAI chart about patterns over time for overdose rates under/over age 30.

I believe state is trying to say: all the deaths from illicit fentanyl are somehow the fault of the pharmaceutical distributors. Because: trends? It's a reach.

#WAOpioidTrial I say it's a reach because: 94-97% of people who take their own RX opioids DO NOT become addicted or move on to heroin, etc. (The rate varies depending on which survey/source, but the number is always above 90%). The facts do not support state's argument.

#WAOpioidTrial For example:

"An estimated 4 to 6 percent who misuse prescription opioids transition to heroin."

So 94-96% of people who MISUSE RX opioids NEVER move to heroin. Source? NIDA. National Institute on Drug Abuse.

drugabuse.gov/drug-topics/op…

Just so we're clear - that's not 4-6% of ALL people who take RX opioids for pain. It's 4-6% of those who MISUSE RX opioids, and that doesn't even specify "which were prescribed TO them" - it means all people who can find RX opioids somewhere. It's a LOW number.

#WAOpioidTrial Back to the trial - State asks Dr. Banta-Green if "Washington state is experiencing an opioid crisis."

He pauses. "Yes - it has many factors, but yes."

Because he knows. The opioid FATALITY crisis is almost entirely heroin & illicit Fentanyl. Plus a lot of Meth.

#WAOpioidTrial State is really trying to focus on adolescents and under-30 deaths/impacts.

Every drug poisoning death is a tragedy. Losing young people even more so.

I do not think any reasonable person can lay this at the feet of legal, pharmaceutical distributors. 🤷🏽‍♀️

#WAOpioidTrial Just before the AM break Dr. Banta-Green was explaining that overdose fatalities were exceptionally higher among the unhoused, and among incarcerated people upon release. These populations are extra-vulnerable due to lack of access to treatment, low tolerance, etc.

#WAOpioidTrial And we're back from AM break. Dr. Banta-Green was asked about the impact to indigenous peoples and he says clearly - the impact has been worse here for those populations than the national average. Which is true. And tragic.

#WAOpioidTrial Now state asks Dr. Banta-Green about his experience combating the opioid crisis & whether he has been frustrated by the lack of progress. He says yes. State asks why. Defense objects. Judge sustains.

BECAUSE HE IS NOT AN (disclosed) EXPERT WITNESS.

Yep. Still.

#WAOpioidTrial Dr. Banta-Green is talking about 'low-barrier care" for opioid use disorder, and it's all perfectly on-point. He is 100% right. Getting people who WANT treatment into MAT treatment quickly and easily is the best way to keep them alive. MAT works. Facts is facts.

#WAOpioidTrial Dr. Banta-Green points out that the healthcare system is intolerant of people being late, or missing appts. And requiring people to go to 3 appts with different specialists before getting access to 'lifesaving medication' is untenable.

Ahem. Also true for pain.😬

#WAOpioidTrial HOO BOY. State just asked Dr. Banta-Green if "WA state has the workforce needed to manage the opioid crisis" and he says no. Which we don't.

WA state also has only a handful of pain specialists for our state of 7.6 million people.

ALL patients deserve care.😠

#WAOpioidTrial State is asking about how helpful Naloxone is in getting people access to care. And getting unhoused people into housing is urgently needed.

Where is state going with this? Should the pharmaceutical companies pay for Naloxone and housing for WA state? Or what?

#WAOpioidTrial State is asking how to help incarcerated peoples upon release. Dr. Banta-Green is talking about the severe challenges that population faces in seeking employment, respect, and how it would take lots of services and years of outreach. Same with indigenous peoples.

#WAOpioidTrial Dr. Banta-Green is elaborating about the stigma of substance-use disorders and how clinicians 'don't want 'those people' in their clinics'.

All true. People think people 'choose' to use opioids and they should just choose NOT to use opioids. Stigma is terrible.

#WAOpioidTrial While that is all true - and terrible - I'm unclear what the state's point is with this testimony. Addiction existed long before RX opioids were prescribed (like more than a hundred years before). Long before the defendants' companies ever existed.

#WAOpioidTrial Even if - BIG IF - someone thinks the defendants are responsible for the illicit fentanyl/heroin/meth crisis (and I do not see how), is state saying they should fund ALL state efforts to address this crisis? How could they be responsible for ALL the state's SUDs?!

#WAOpioidTrial I mean, alcohol factors in to a substantial minority of overdose fatalities here in WA - are the pharmaceutical distributors responsible for alcohol-related fatalities as well?

(Because no. No they are not.) Sigh.

#WAOpioidTrial And on that note, state tenders the witness.

Defense counsel for Cardinal takes point on questioning Dr. Banta-Green on cross.

As a fact witness. I guess.

#WAOpioidTrial LOLOLOL

And the very first question from defense raises an objection from state "lack of foundation, requires expert witness testimony" FROM STATE'S WITNESS Dr. Banta-Green. Which state very carefully and repeatedly said he was NOT an expert witness.

#WAOpioidTrial State's strategy to keep Dr. Banta-Green as a fact witness seems to have bit them in the butt. Judge overruled a few state objections about the Qs asked of Dr. Banta-Green, then said (to state):

"You've tried to thread this needle and I don't understand why."

#WAOpioidTrial Again I'd need a trial lawyer to explain all of this really - but it seems as if state's strategy to keep the state's FOREMOST EXPERT on addition/overdose as a fact witness is completely benefiting the defense. D'oh.

#WAOpioidTrial Defense continues to ask Dr. Banta-Green questions, state objects to nearly every single one, and the Judge is overruling nearly all state objections.

Judge: "We could avoid nearly all of these arguments if we could just admit that the witness IS an expert . .."

#WAOpioidTrial To sum up: State desperately worked to elicit LIMITED opinions from Dr. Banta-Green because they DO NOT WANT him as an expert. For reasons.

Now that defense has a crack at him, judge is allowing them the same leeway.

#WAOpioidTrial So far defense has got Dr. Banta-Green to confirm statements that prior to the 1990s, heroin was the biggest drug problem here in WA. And that nearly all counterfeit pills made to look like opioids contain fentanyl. Which they do, as state crime lab reports say.

#WAOpioidTrial Defense: Meth use has increased significantly in WA, yes?

State: Objection ... vague?

Judge. No.

🤦🏽‍♀️

#WAOpioidTrial Now the defense is asking about this chart, in this document (found online) which Dr. Banta-Green himself published:

State objects: "Calls for an ... expert opinion."
Judge: SERIOUSLY. Overruled.

adai.uw.edu/pubs/infobrief…

#WAOpioidTrial Generally speaking, defense is getting Dr. Banta-Green to confirm that prior to the 1990s most RX opioids were prescribed for end-of-life or cancer pain ONLY, and that prescribing trends changed to include prescribing opioids for chronic, non-cancer pain.

#WAOpioidTrial Defense is bringing up the WA state legislation in 1999, what we refer to here as the "intractable pain laws"; since revoked.

They were great. It's tragic that they were revoked, IMHO, as they were REASONABLE.

They are here: apps.leg.wa.gov/documents/laws…

#WAOpioidTrial The fight over Dr. Banta-Green's role continues. The objections have been flying.

The judge has excused Dr. Banta-Green for the SECOND time to admonish both sides about trying to elicit opinions vs. facts. Everyone knows HE IS AN EXPERT.

The arguing continues.

#WAOpioidTrial Defense: "Do you agree with the statement that there was a 300% increase in opioid prescribing?"

State: "Objection, vague about time period."

Defense: "Since the late 1990s?"

State: Crud.

Dr. Banta-Green: "Yup."

#WAOpioidTrial Because of this nonsense about Dr. Banta-Green's 'fact witness only' role getting through questioning is like paddling upstream. Everything takes 3x longer to get through objections, rulings, rephrasing.

I don't think our efficiency-appreciating Judge is a fan.

#WAOpioidTrial AND that's lunch, folks. Back in 90 minutes, or around 1:30pm PT.

This is so far the weirdest part of the trial. Ciao!

#WAOpioidTrial Day 20 resumes with this link for the afternoon.

Interestingly - state's next in-person witness has refused to take a PCR test prior to entering the courtroom, so they're .. not going to call her, whomever it is.

We're back with Dr. B-G!

#WAOpioidTrial Specifically, defense continues their cross-examination of "fact witness" Dr. Caleb Banta-Green. We're reviewing his (extensive - and I do mean extensive) C.V. including "Select Opioid-Related Publications" he's authored or co-authored. It's a lot.

#WAOpioidTrial My theory is: since they cannot ask Dr. Banta-Green is OPINION as a fact witness, they can pull up some of his MANY published articles and get him to read his own quotes and statements into the record. Right?

We shall see.

#WAOpioidTrial -Whoops - Defense IS, in fact, asking Dr. Banta-Green if he agrees/confirms statements from a paper about "perceived undertreatment of chronic pain" - but he's not a pain specialist. Nor has he ever treated chronic pain. One of his co-authors would have written it.

#WAOpioidTrial Interestingly, defense is asking Dr. Banta-Green about the first AMDG guideline from 2007.

In which some very familiar local players (cough cough - PROP executives) played key roles. Let's see where this goes.

At least one PROP VP has been named directly.

#WAOpioidTrial Aaaand state continues to object about how he's not an expert witness (ridiculous) so these questions lack foundation.

The judge continues to mostly overrule the objections. Let's watch.

#WAOpioidTrial Aha - defense is asking about 2010 WA ESHB bill 2876 - which is apparently what REVOKED the earlier 1999 intractable pain laws.

Guess who sponsored the bill? A 30-year addiction counselor from Kaiser, House Rep Moeller (Now retired).
lawfilesext.leg.wa.gov/biennium/2009-…

#WAOpioidTrial Guess who testified in support of this bill, to repeal the intractable pain laws?

Why, the VP of PROP, of course.

To recap: The revocation of the 1999 WA state intractable pain laws - AND the first opioid prescribing legislation in the nation - were authored by this guy: an addiction counselor. And supported by people who went on to form PROP. No pain docs present.

web.archive.org/web/2016100617…

#WAOpioidTrial Oh dear. Dr. Banta-Green is saying that he heard from his medical doctor colleagues (he named Gary Franklin and Michael von Korff, both PROP executives) that long-term opioid use caused 'increased pain sensitivity', or Opioid Induced Hyperalgesia.

Umm .. .

#WAOpioidTrial Yes many medical professionals who do not support long-term opioid therapy warn patients and colleagues about OIH. Only .. while ALL patients are warned of it, the prevalence is .. . scant.

https://twitter.com/StarvinLarry/status/1344337632034217985?s=20

#WAOpioidTrial Meanwhile, back in the trial .. state continues to object to many questions posed to Dr. Banta-Green. When he's asked about papers he's published and what they said.

They are mostly overruled, still.

#WAOpioidTrial Defense is asking Dr. Banta-Green about the 2016 CDC Opioid Prescribing guidelines.

State objects.

Judge overrules.

Just .. . 👀

😬

#WAOpioidTrial Defense pulls up a slide Dr. Banta-Green made from .. .um, earlier, there was some data confusion - saying: "Good news! We are now experiencing a 50% decline in RX use." Meaning: RX opioid fatalities were declining significantly.

#WAOpioidTrial From a 2015 WA press release:

"Our state's ability to SHIFT THIS EPIDEMIC INTO REVERSE has been the result of strong partnerships ... " etc. etc said study lead author Gary Franklin, Medical Director, WA state Dept. of Labor & Industries.

Soo. It was fixed?

#WAOpioidTrial We're in the PM break. My favorite thing so far was when defense asked Dr. Banta-Green about a paper he co-authored with a survey in it. Defense objected, apoplectic BECAUSE OF THE EARLIER SURVEY RULING BY THE JUDGE.

Judge overruled because - it's the doc's paper.

#WAOpioidTrial If I had to guess, some lawyers might be going to be having nightmares and mumbling "SURVEYS!" tonight.

🤣

#WAOpioidTrial We're back! Defense is asking Dr. Banta-Green about an email he sent in 2013. Good times.

#WAOpioidTrial Someone from DSHS asked Dr. Banta-Green via email if the decrease in morbidity/mortality from RX opioids had any relation to the increase in same due to use/misuse of heroin?

He answered (I'm paraphrasing): It's complicated.

#WAOpioidTrial In an email thread from 2014, Dr. Gary Franklin quotes the "80% of heroin users started on rx opioids" and asks Dr. Banta-Green if that's true.

Dr. B-G replies: 'most aren't abusing their OWN opioids'; and - basically, it's complicated. Not that simple.

#WAOpioidTrial We're now reviewing an editorial Dr. Banta-Green wrote in 2012:

deepdyve.com/lp/american-me…

#WAOpioidTrial

Defense: "Dr. Banta-Green do you agree that addiction is a disease?
Dr. Banta-Green: Generally, yes.

D: Not limited to opioids, yes? <names other things>
Dr. B-G: Yes.

We are getting to polysubstance use here, folks. Where will we go?

#WAOpioidTrial Ah, we're getting to what the defense is calling "medicine cabinet misuse" - the highest % of RX misuse.

We're looking at a slide Dr. Banta-Green presented which says: "The vast majority of pills RX'd post-op are left over; may be used for misuse or diversion"

#WAOpioidTrial Defense is asking about Dr. Banta-Green's thoughts on addiction treatment, and if there's one-size-fits all.

He replies: I believe we have a strong evidence base which people should be provided with so they can make an informed decision.

Sniff sniff. ❤️

#WAOpioidTrial McKesson's counsel asks to cross Dr. Banta-Green in addition to Cardinal, and state objects because "we didn't cover any company-specific stuff, and we object to EACH defendant questioning the witness".

So then may be don't sue multiple defendants together?

🤔

#WAOpioidTrial Anywho, McKesson's counsel is now questioning Dr. Banta-Green.

During the Purdue trial Dr. Banta-Green apparently testified that 90% of the adult population has been prescribed an opioid in their lifetime.

State objects. Judge - pensively - overrules.

#WAOpioidTrial Okay NOW the judge looks annoyed. The state objected again - I don't even know how many this is now, it's dozens - about asking Dr. Banta-Green stuff and even with a mask on his face, judge's face looked TICKED. He said: "You (state) asked him PLENTY of stuff."

#WAOpioidTrial So what defense (McK) is trying to get on the record is that MOST adult people have been RX'd opioids for pain, generally acute pain, in their lifetime.

And I think he's probably getting to - and yet: The rate of OUD remains low, and stable. (If I had to guess.)

#WAOpioidTrial McK is asking Dr. Banta-Green how many people started long-term opioid therapy and about percentages ... and of course the state objected, and then the judge overruled.

Defense isn't prevailing on ALL the objections ... but most of them.

#WAOpioidTrial Defense is trying to get this editorial which Dr. Banta-Green co-wrote admitted into the record.

acpjournals.org/doi/10.7326/m1…

#WAOpioidTrial McKesson is showing a chart from the ADAI site which shows that RX opioids dispensed daily in WA is roughly the same now (well, 2020) as it was in 2000.

Because it's true, opioid prescribing is now at a 20-year low. Yet the fatality rates are much, MUCH worse.

#WAOpioidTrial We're looking at this ADAI chart:

Note that the red line is Buprenorphine, and Methadone appears twice: once for pain, once for OTP (opioid treatment programs) or MAT.

adai.washington.edu/WAdata/ARCOSop…

#WAOpioidTrial Defense has been working mightily to lay the foundation to ask Dr. Banta-Green: Patients with chronic non-cancer pain perceive that opioids are effective at treating their pain, yes?

I'm not sure that he'll get there today before court adjourns.

#WAOpioidTrial In a funny moment, state OBJECTED (again) to defense's question of Dr. Banta-Green.

The question was: "Do you see this paragraph displayed on the big screen from this article you co-authored?"

State: OBJECTION!

Judge: Um. To whether he sees it?

🤣🤣🤣

#WAOpioidTrial Aaand on that note we're done for the day. McKesson will resume cross of Dr. Banta-Green in the morning -briefly- and so on.

It's been a fascinating day. Also I wonder who the heck refused to take a COVID PCR test at the courtroom who is on the state's list? Ciao!