Thread by @funchefchick

#WAOpioidTrial Day 22 is now starting; WA state vs. McKesson, et al can be watched here for the morning session (then the link disappears at the lunch break).

We resume with the depo from a Cardinal employee being played; most of which we saw last Thurs.

#WAOpioidTrial Once again the questions are about how the pharmaceutical distributors offered marketing/ad opportunities to the manufacturers.

Which somehow makes the distributors liable for the 'opioid crisis' which is almost exclusively polypharma heroin/fentanyl/meth. M'kay.

#WAOpioidTrial The rules of evidence remain ... elusive.

Somewhat lengthy technical discussion about whether the witness in the depo could refer to 'notes' about facts about a doc she had not seen.

Cardinal's objection is sustained! (I have no idea about why, but okay!)

#WAOpioidTrial And we're done with that depo! State calls a new in-person witness: notable and respected harms reduction expert (among other things) doc and professor Dr. Dan Ciccarone. Let's see where this goes.

profiles.ucsf.edu/daniel.ciccaro…

#WAOpioidTrial Dr. C is telling the story of interviewing a person using heroin, asking him how he started. He was a truck driver who developed a spine injury, who had been getting RX opioids and managing just fine. Then the doctor cut him off abruptly. He shifted to heroin.

#WAOpioid Ironically, this story illustrates what many have been saying: people w/REAL pain issues who had been stable on RX opioids who were abandoned .. .no longer had pain relief. This is not the story of a person getting high from heroin. This is a person w/untreated pain.

#WAOpioidTrial Dr. C wrote this paper in 2013. I have no doubt that some people - non-medical users as well as pain-relief-seeking CPP - DID shift to heroin in desperation.

The data is still clear that among those taking their own RX . . it's VERY LOW.

ncbi.nlm.nih.gov/pmc/articles/P…

#WAOpioidTrial This quote:

"From the accounts of younger/recent heroin injectors in this study, it is evident that since the rise of the opioid pill epidemic, the barriers to heroin use and to injection have been reduced by the normalized pervasiveness of these pharmaceuticals."

#WAOpioidTrial The point of which is: when RX pills made their way to the illicit market due to MANY more being dispensed, carelessly stored, sold, etc: More people felt safe to take them when they'd previously avoided heroin. This is true. And accurate: RX pills WERE safe.

#WAOpioidTrial Well, RX pills were SAFER, at least.

When the DEA/DOJ moved to dry up the RX opioid supply: they left ALL THOSE PEOPLE out in the cold with nowhere to go. No safe supply. Inadequate harms reduction. No access to affordable/effective rehab programs. 🤬

#WAOpioidTrial And JUST as awful: The DEA moved to dry up the supply of RX opioids FOR LEGITIMATE PAIN OF ALL KINDS. Acute. Surgical. Chronic. Cancer. End of life.

They didn't focus on illicit opioids. They deprived MOST OF AMERICA of adequate pain care. Millions of us.

#WAOpioidTrial And the cost in human lives and human suffering has been unprecedent in modern medicine.

The DEA and their partners have systematically attacked every piece of the LEGAL prescribing chain. Well .. just about every piece.

#WAOpioidTrial Dr. C: "Some people frankly felt abandoned by their medical providers and resorted to street use if only to ameliorate their pain."

YES. VERY MUCH THIS.

#WAOpioidTrial Dr. C is obviously not wrong about the causal links from RX opioid pills to heroin use.

HOWEVER. There are sufficient studies which articulate that this is limited to those who sought RX opioids for non-medical use.

Which were mostly illicitly obtained.

#WAOpioidTrial There are copious studies which show that people taking their own prescribed opioids RARELY developed SUDs, and even more rarely ever transitioned to heroin use. The numbers are SO small.

#WAOpioidTrial Oh hey hi I'm back - had to step away from the trial earlier so I missed the last hour or so of Dr. C's testimony. Court resumes this afternoon at this link. I believe McKesson's defense counsel is about to question Dr. C on cross.

#WAOpioidTrial After the judge rules on some motions here, which is what we are doing currently.

Dunno what they are - let's see!

#WAOpioidTrial Okay something big (and legally technical) was just decided but I could not tell you for the life of me what it was.

BUT - I think it was in favor of the defense. If I am guessing correctly. ? And onwards with the cross-examination of Dr. C. by McKesson!

#WAOpioidTrial Apparently before lunch there was some testimony about an increase of HiV infection (due to heroin use? Presumably?). Something about the population studied was already at a higher rate of HiV infection than the general population .. ?

#WAOpioidTrial Ah, the point McK's counsel was teasing out was that among this population, at least some of them did not proceed from RX opioid to heroin, but were using both either intermittently or simultaneously.

Dr. C confirms that this is true, for some of them.

#WAOpioidTrial Dr. C testified earlier that - with some variation by region - the rate of people who reported misusing RX opioid prior to starting heroin ranged from 39-86%.

But that's nationwide. None of that data was from WA. Dr. C did not do any specific research about WA.

#WAOpioidTrial To be clear: Dr. C is a GREAT doctor doing EXCELLENT work. I have no criticisms of his work or his statements.

I do think that most of his work is not applicable to chronic pain patients/people stable on long-term opioids.

#WAOpioidTrial We're back to looking at this study. Page 3 for those who have access to the full article.

pubmed.ncbi.nlm.nih.gov/23061326/

#WAOpioidTrial And now we're looking at this:

SPECIFICALLY: 'However, the vast majority of NMPR users have not progressed to heroin use. Only 3.6 percent of NMPR initiates had initiated heroin use within the 5-year period following first NMPR use.'

samhsa.gov/data/sites/def…

#WAOpioidTrial That is correct: 96.4% of people who MISUSED RX opioids did NOT transition to heroin use within 5 years.

That's ... a VERY high percentage.

#WAOpioidTrial It's a version of that old adage:

Many people who use heroin previously misused RX Opioids.
But conversely. very FEW people who misused RX opioids ever used heroin.

Don't confuse those two facts.

#WAOpioidTrial Now looking at Dr. C's earlier Congressional testimony, Winter 2020, which can be found here

'No Moral Panic: Public Health Responses to Illicit Fentanyls'

via.library.depaul.edu/cgi/viewconten…

#WAOpioidTrial In which we find this quote:

" This exponential increase in drug-related
death rate was not defined by any specific class of drugs. '

Hmm.

#WAOpioidTrial And: 'Each era has
its problematic drug defined by supply or by cultural desire, but there may be underlying drivers of problematic drug use leading to death that are independent of the class of drug that continue to get worse over time. '

#WAOpioidTrial And this chart - which shows that the trends of overdose fatalities from ALL substances has been on a uptick/trend line since 1979.

#WAOpioidTrial And from the abstract of this piece from SCIENCE:

science.org/doi/10.1126/sc…

#WAOpioidTrial I dunno why that pasted weird but there is NO TIME to redo it!
Currently on: US regional & demographic differences in prescription opioid &heroin-related overdose hospitalizations pubmed.ncbi.nlm.nih.gov/28688539/

#WAOpioidTrial Heh. Defense asks Dr. C if "FDA is aware of the known and evolving risks of opioid medications and that they weigh them against the benefits"

State objects. Why? "Scope?"

Srsly? Dr. C isn't aware of the FDA weighing risks and benefits of opioids? 🤦🏽‍♀️

Overruled.

#WAOpioidTrial 'Pain has also been identified as a poorly addressed clinical and public health problem for which treatment with prescription opioids may play an important role.'

NEJM, 2016.

nejm.org/doi/10.1056/NE…

Although the majority of current heroin users report having used prescription opioids nonmedically before they initiated heroin use, heroin use among people who use prescription opioids for nonmedical reasons is rare, & the transition to heroin use appears to occur at a low rate.

#WAOpioidTrial 'Yet, taken in total, the available data suggest that nonmedical prescription-opioid use is neither necessary nor sufficient for the initiation of heroin use and that other factors are contributing to the increase in the rate of heroin use and related mortality.'

#WAOpioidTrial Those last two were the same citation, btw. Note that this citation was NOT Dr. C' s - he's being asked about these statements. It appears he does not entirely agree with them. But lead author of that pieces is Deputy Director of NIDA. ??

nida.nih.gov/about-nida/org…

#WAOpioidTrial We are on the mid-PM break, btw, and court will resume right around 3pm.

I, however, gotta duck out right around then for a medical appt sooo .. . I'll ask friends to fill me in on what I miss and hopefully post some later updates. ! 🤞🏽