Thread by @funchefchick

#WAOpioidTrial Day 23 is now starting. Good morning!

Here's the AM link. Also it is snowing here this morning, WTF??

#WAOpioidTrial IANAL here but it seems like the state just got admonished a bit for trying to pull some exhibit back OFF the record after defense went to the expense of reviewing; state doubles down and says they are SURE it will be in; then tried to pull it. Judge said nope.

#WAOpioidTrial And now we resume McKesson's counsel cross-examining Dr. Daniel Ciccarone, MD, MPH. He's a widely respected harms reduction expert (among many other things). He's been testifying about the uptick in heroin/fentanyl use, generally.

#WAOpioidTrial We heard previously in the trial that EVERY SINGLE 'blue m30' counterfeit pill seized in WA was contaminated with illicit fentanyl. These pills have killed MANY. This image is from this report last summer:
snohomishcountywa.gov/ArchiveCenter/…

#WAOpioidTrial: From same report:

CURRENT DRUGS– FENTANYL & METH
The most trafficked drugs in Snohomish
County are fentanyl and methamphetamine. Heroin is third with cocaine and
other substances falling further back in
popularity.

No mention of RX opioids whatsoever.

#WAOpioidTrial We are now looking at this document. Authored by: Dr. Caleb Banta-Green, who testified previously as a (chortle) 'fact witness' (NOT as an 'expert). Which will never be not funny.

ANYWAY. It's fentanyl. Because of course it is.

adai.uw.edu/wordpress/wp-c…

#WAOpioidTrial From elsewhere in that same ADAI report:

"However, many people are quickly becoming addicted to opioids who have used no opioid other than fentanyl and have never injected it."

Which is true. At least here in WA, although I'd expect elsewhere as well.

#WAOpioidTrial Current line of questioning involves 'how did (legit) RX opioid pills get diverted'; basically - aside from upstream diversion (boxes falling off trucks, pharmacy inventory going missing, etc): someone had to prescribe those pills, yes? Yes.

#WAOpioidTrial "Normalized pervasiveness" is not a term I'd heard - but is being used to describe the prevalence of legitimate RX pills on the street, which led to . . people taking them. Instead of taking something else. They were 'ubiquitous'.

#WAOpioidTrial: Dr. C: "People took them because they thought they were safe - they were a known dose, etc."

Yes. And they were, in fact - safer than the counterfeit RX pills now. They were a known dose. And far less people died even when they misused those RX pills. Sigh.

#WAOpioidTrial "Doctors weigh the risks and benefits of prescribing opioids for each patient based on their particular needs and condition and history, correct?"

Lord we'd hope so. Instead of them being threatened away from even considering prescribing pain relief. Sigh.

#WAOpioidTrial "Doctors expose patients to opioids because they have a medically appropriate uses, correct?"

State objects, saying it is 'out of scope' for DR. CICCARONE. 🙄

Judge - after considering - overrules.

#WAOpioidTrial "Opioids play a crucial role in medicine, correct?"

Dr. C: "It's a complicated AND crucial role"

#WAOpioidTrial Oh dear. Dr. C says the 'evidence is moving away from the use of opioids for chronic pain'.

Argh. I'm going to put a pin in this for later. Because reasons.

Meanwhile, McK brings up a deposition of Dr. C from the WV trial ...

#WAOpioidTrial Whoops, my bad - the RI trial. In which he said - basically - that opioids are appropriate for the treatment of acute and chronic pain in certain circumstances. So yeah.

#WAOpioidTrial McK asks Dr. C if he is aware that 1/3 of Americans have taken prescribed opioids in the past year.

Dr. C says he hasn't seen that data . . .

I haven't seen that data myself .. . so let's see it. !

#WAOpioidTrial In the earlier depo, Dr. C apparently said "their estimate is 38%", based on . . some paper not referenced in the depo we are seeing.

I gotta find that paper, apparently.

#WAOpioidTrial: "Not everyone who takes prescribed opioids becomes addicted, correct?"

Dr. C: Correct.

YEA VERILY. By like a huge number. As I am sure we will see introduced next.

#WAOpioidTrial We're looking at this for chronic non-cancer pain: rate of OUD was 0.12% for low dose/acute; 0.72% low dose/chronic; 0.12% for med dose/chronic; 0.12% for high dose/acute, & 6.1% for high dose/chronic.

Overall: VERY LOW rates of OUD.
pubmed.ncbi.nlm.nih.gov/24281273/

#WAOpioidTrial Other than that last category? Literally 99% of people who took prescribed opioids EVER did not develop OUD.

For high dose/chronic use - 95.9% NEVER developed OUD.

Sigh. THIS. THIS RIGHT HERE. The chronic pain community has been devastated DESPITE this data.

#WAOpioidTrial Yes, that is only one study. But most of the studies in this space have very similar numbers.

Despite the #LitigationNarrative, despite the media narrative and the $#$%! Dopesick nonsense .. MOST people do not develop addiction from RX opioids. Sigh.

#WAOpioidTrial A small percentage - 2-2.5% based on NSDUH and NIDA data - DO develop OUD from taking opioids and for those people we DO need affordable, accessible treatment options. And people DO need to be aware of the risks.

But for the love of all that is holy: TREAT PAIN.

#WAOpioidTrial "3-4% of the adult population (9.6 million to 11.5 million persons) were prescribed longer-term opioid therapy" per NIDA's (Dr. Nora Volkow) reports.

This is a #DisabilityRights issue. Don't get it twisted.

#WAOpioidTrial "In 1980, acute pain was so frequently treated w/opioids that propoxyphene was the second-most dispensed drug in the United States."

ncbi.nlm.nih.gov/pmc/articles/P…

#WAOpioidTrial "The Carter White House stated, “Diversion, misuse, and abuse of legal drugs may be involved in as many as seven out of ten reports of drug-related injury or death."

#WAOpioidTrial"A decade later, US medicine was shaken by revelations of undertreated chronic pain, motivating normative practice and policy shifts. Previously chronic pain was managed largely with cognitive behavioral therapy, even hypnosis."

THINK your pain away. Just like now.

#WAOpiodTrial "An Institute of Medicine report attributed the rise in chronic pain prevalence during the 1990s to the following"

- people wanted pain relief
- people lived longer
-People survived complex surgeries and cancers more
-surgeries got more complex

In other words ..

#WAOpioidTrial Medical science improved so that we could SAVE people from traumas and diseases where previously they would die. Which is wonderful.

But when you SAVE a person and leave them in severe pain for the rest of their lives . .. they deserve pain relief. Right??

#WAOpioidTrial We're now looking at this document, co-authored by Dr. C.

Basically: There were many factors which led to the 'opioid crisis'.
- unchecked and poorly understood prescription paradigms
-mandated recognition of pain as the 5th vital sign

pubmed.ncbi.nlm.nih.gov/33316051/

#WAOpioidTrial (continuing)

- limited education on pain management (!!!!)
- underestimation of risks and overestimation of benefits of opioids

Significant gaps in medical education about pain, especially CNCP . ... yeah. THIS IS STILL A THING.

#WAOpioidTrial It looks like where McK's counsel is going with this is:

DOCTORS prescribed opioids. Lots of them. Because: We were SHAKEN by the undertreatment of pain in America in the 1990s. Which was true.

So then ... it looks like McK is trying to say 'blame docs'?

#WAOpioidTrial Which doesn't seem . . very fair.

The truth of it is: People WERE in pain. They still are. Opioids are the only proven effective analgesic in medicine for *severe* pain (yes there are many tools in the toolbox - but in surgery? Opioids.)

Ethically speaking..

#WAOpioidTrial NO doctor, or pharmaceutical manufacturer, or distributor, or ANYONE predicted the rise and lethality and prevalence of illict fentanyl. NO ONE.

Humanity is complicated. No one actor IS responsible for the 'overdose crisis'. And yet ...

#WAOpioidTrial I shared this yesterday, but here is again. Circle added.

DESPITE it being true that no ONE company or actor can be liable for the overdose crisis.

Here's where we are with this trial. Note the number of players. Note that ALL are governed by DEA oversight.

#WAOpioidTrial Aaand we're on the morning break. McK was continuing with "sometimes even well-intentioned doctors wrote RX for more opioid pills than were needed, yes?" -type questioning.

Please let's not throw our doctors/ARNPs under the bus, people! 99% did not dev OUD!

#WAOpioidTrial ANYWAY I think McK's point here is - if doctors wrote these RXs, then how on earth could distributors be the problem? Distributors did not have visibility on RXs and whether they "seemed medically appropriate". Which is true. This whole trial . . shenanigans.

#WAOpioidTrial Doctors & ARNPs & EDs used to *believe* patients when they said they were hurting; be sympathetic, even. This is no longer the case. They've been squeezed by DEA into approaching patients in pain with suspicion & caution.

Leaving patients in pain. And mistrust.

#WAOpioidTrial The AMA released this last Sept:

"AMA is greatly concerned by widespread reports of patients with pain being denied care because of arbitrary restrictions on opioid therapy or a lack of access to affordable non-opioid pain care."

ama-assn.org/press-center/p…

#WAOpioidTrial As well as:
- Opioid RX has decreased by 44.4% in the last decade
- more docs use PDMP than ever
- Lots more docs got x-waivers for Bupe
- yet 80 to 90 percent of people with a substance use disorder receive no treatment.

The results have gone BADLY in every way.

#WAOpioidTrial Anyway we're on a break! Getting some coffee. Trial resumes any minute.

#WAOpioidTrial Ohai, we're back already.

McKesson's counsel is asking Dr. Ciccarone about RX opioid pill diversion - from medicine cabinets, from .. wherever those pills come from when they show up on the streets.

#WAOpioidTrial Interesting. The WA legislature has determined that 'home medicine cabinets are the most common source of RX drugs that are diverted and misused.'

See: (2)

app.leg.wa.gov/RCW/default.as…

#WAOpioidTrial McK: "There's always going to be some degree of opioids being prescribed to fulfill legitimate medical needs in Washington state, yes?"

Dr. C: Correct.

Yep. And no one knows that amount. Because it will vary by individual patient need. Always.

#WAOpioidTrial McK: "And pharmacies gotta dispense them, right?"

Objection by state - Dr. C isn't a pharmacy expert. True. Judge sustains.

#WAOpioidTrial McKesson keeps trying to ask this in different ways - "distributors only ship meds to pharmacies based on orders they've requested, to fulfill RX written by doctors . .. " but state keeps saying no foundation, out of scope. Let's see if McK can get there.

#WAOpioidTrial Hmm. McK pulled up an earlier trial transcript where Dr. C was asked: "you agree with this proposition that what the distributors shipped to pharmacies reflected what the doctors were prescribing?"

And Dr. C said: Yes.

(Lots of arguing about this tho)

#WAOpioidTrial The last defense question for Dr. C on cross was:

"In all your research into 'oversupply' you never focused on any research into the DISTRIBUTORs, correct?"

Dr. C: Correct.

Yep. Read into that what you will.

State is now starting redirect.

#WAOpioidTrial State is now cherry-picking various statements out of this paper from 2017:

pubmed.ncbi.nlm.nih.gov/27544696/

#WAOpioidTrial Like state is showing: "Nearly half indicated they were first exposed to opioids through a prescription from their physician to treat pain."

Ignoring: Our results indicate that pain patients who developed a substance use disorder were rarely drug naïve prior . .

#WAOpiodTrial 'rarely drug naïve prior to receiving their first opioid RX. Rather, most have an extensive history of psychoactive drug use. As such, physicians should routinely ascertain complete licit & illicit drug histories in patients for whom they prescribe opioids.'
RIGHT?!

#WAOpioidTrial I 100% agree that all physicians/ARNPs should get full medical histories including licit and illicit drug histories on EVERY patient prior to prescribing ...

ANYTHING, dammit. Including opioids. Jeesh. Isn't that basic medical standards/practice?!! 🤔

#WAOpioidTrial Now reviewing this paper from 2016. Which is LONG before the CDC admitted that they had miscounted opioid overdoses DRAMATICALLY.

When everyone thought opioid overdoses were from RX pills. Not illicit fentanyl. We didn't know it yet.

nejm.org/doi/full/10.10…

#WAOpioidTrial For anyone late to the party - the CDC admitted they counted those numbers VERY wrong in 2018. In JAMA? No. NEJM? No. Pain? Science? AAPM? Anesthesiology?

No. The American Journal of Public Health. In an editorial. Quietly.

painnewsnetwork.org/stories/2018/3…

#WAOpioidTrial Then in June 2019 the CDC admitted their opioid guidelines had been 'widely misinterpreted'. And blamed doctors for doing so.

This time, in NEJM.

painscale.com/article/cdc-ad…

#WAOpioidTrial BUT HEY back to the trial. State is having Dr. C say: if not for the 'enormous wave' of RX opioids hitting the streets, we'd have far less people using heroin. By an order of magnitude.

Looking at this article Dr. C co-authored in 2013. ncbi.nlm.nih.gov/pmc/articles/P…

#WAOpioidTrial Now we are here - the hardest to understand title ever? 'AN INSTRUMENTAL VARIABLES APPROACH TO ESTIMATING THE EFFECTS OF CHANGES IN THE HEROIN MARKET ON OVERDOSE IN THE US'

canadiancentreforhealtheconomics.ca/wp-content/upl…

#WAOpioidTrial State is now asking Dr. C to look at (illicit) fentanyl death trends in WA state since 2017, from the ADAI site and charts.

They've gone up. VERY up. Because illicit fentanyl is lethal. And rather than encourage safe supply . . draconian prohibition. It's deadly.

#WAOpioidTrial It's also true that illicit fentanyl did not enter the PNW market until much, much later than the east coast. We continued to have black-tar heroin as the leading illicit opioid for much longer than you'd have expected.

Now it's illicit fentanyl, heroin, & meth.

#WAOpioidTrial Dr. C is intensely stating his fear and concern about counterfeit pills. This is what is keeping him awake at night right now.

"Fentanyl is a powerful drug. Most humans are vulnerable to the potency."

No objections from me. All true. All terrifying.

#WAOpioidTrial Also true: the drug DISTRIBUTORS have zero responsibility or accountability for bad actors MAKING COUNTERFEIT MEDICATIONS OF ANY KIND.

I cannot stress this enough. Say whatever you like about whether licit drug use let to illicit (generally untrue, but whatev)

#WAOpioidTrial BUT the distributors have NOTHING to do with counterfeit pills.

Just .. No. This is a completely unrelated issue.

I might need a snack. This is making me crabby. 😠

#WAOpioidTrial Seriously the state is asking Dr. C about a study from 1954 which showed that 17% of opioid addicted men .. .

Just. I stopped listening. Men only. 1954. Addicted to opioids from a time when rx opioids barely existed.

Bleh.

#WAOpioidTrial Aaaaand the state's last line of questioning was objected to, and judge sustained it.

We're about to break for lunch. Oooh, we're discussing the Ruth Carter exclusion motion. To recap: Defense has moved to EXCLUDE all of her testimony. Arguments Monday.

#WAOpioidTrial And that's lunch, people! Back at 1:30pm PT for the afternoon session. New link when we resume.

#WAOpioidTrial And we are back! Trial day 23 continues this afternoon at this link. State has called Harvard Health Economist Dr. David Cutler.

#WAOpioidTrial Dr. Cutler is appearing in person, which is always easier to follow. He's this guy. He has apparently testified in previous opioid trials. He also got tenured at Harvard at the age of 32 so he's a smartypants in case that wasn't clear.

hsph.harvard.edu/population-dev…

#WAOpioidTrial He's also the #1 most cited health economist in THE WHOLE WORLD.

Soooo.

#WAOpioidTrial I'm guessing that he will testify how much the overdose crisis has cost the state of WA, as well as the nation. Which is going to be a LOT.

However. I will be interested to see if he can produce granular data for RX vs. illicitly-caused costs. Very interested.

#WAOpioidTrial Looking at this consensus report - or at least, the cover of it.

If you collapse ALL opioids and/or ALL overdoses into one bucket it's way easier to measure impact/cost.

However. It ain't that simple, as we all know.

nationalacademies.org/event/03-02-20…

#WAOpioidTrial Which other litigation has he been an expert it? Commonwealth of MASS vs: tobacco some years back.

Then: the MDL. Multi-District Lawsuit, litigated in Ohio.

Some info here: opioidsettlementtracker.com/faq

#WAOpioidTrial Dr. Cutler states: "Washington is currently experiencing an opioid epidemic".

Cough. As a fan of epidemiology, I will continue to object to the term 'epidemic'. Is it a crisis? You bet. Is a tragic and pressing problem? Absolutely.

Epidemic? I mean. ..

#WAOpioidTrial 'epidemic (ĕp′ĭ-dĕm′ĭk) also epidemical (-ĭ-kəl) n.
1. An outbreak of a contagious disease that spreads rapidly and widely.
2. A rapid spread, growth, or development: an unemployment epidemic.

I mean . . .one can argue that 2nd thing. But contagious disease?

#WAOpioidTrial Hoo-boy. Dr. Cutler states: "The misconduct of ABDC, Cardinal Health, and McKesson was a substantial contributing factor to the opioid epidemic and related harms in Washington."

Ummm. As well as .. .

#WAOpioidTrial Dr. Cutler also states: "A substantial share of the prescription opioid supply was unrelated to medical need."

I HAVE SOME COMMENTS.

Did he/they conclude that without talking to pain specialists and/or pain patients who have been impacted??? Grrr.

#WAOpioidTrial Aha. The esteemed Dr. Cutler came to this opinion by reviewing data collected by ... these guys!

Data analytics to help law firms win HUGE awards! So .. .that seems . . .not at all sketchy.

compasslexecon.com

#WAOpioidTrial Dr. Cutler: "One of the key measures of harms is deaths from opioids."

Absolutely.

Others would be: people formerly treated w/opioids who regained functionality, ability to be employed, improved quality of life. MEASURE THOSE THAT LOST ALL THAT. I'll wait.

#WAOpioidTrial Dr. Cutler seems perfectly reasonable & supersmart to be clear. I believe he's got a ton of excellent analysis to share.

Thing is: I don't think anyone asked him about the OTHER opioid crisis & the costs to patients and providers. I'd love to hear his thoughts.

#WAOpioidTrial Dr. Cutler is talking about the impact of ALL opioid use (hospitalizations, deaths, neo-natal impact, etc). ALL opioids.

To circle back to this paper from 2021:

injuryjournal.com/article/S0020-…

#WAOpioidTrial "In every state examined, there was no consistent relationship between the amount of RX opioids delivered & total injury-related mortality or any subgroups, suggesting that there is not a direct association between prescription opioids & injury-related mortality. "

#WAOpioidTrial HEY DEFENSE LAWYERS: If you haven't admitted this study into evidence yet FIGURE OUT HOW TO ADMIT IT.

LITERALLY: "We did not find a direct association between prescription opioids and injury mortality despite the detrimental effects of the opioid epidemic."

#WAOpioidTrial Dr. Custer is showing a chart which shows a 'large and growing gap between the US and other countries" on mortality rate from OUD 1990-2017.

What that chart excludes is that all other countries have national health care. USA does not. Many of us are on our own.

#WAOpioidTrial Dr. Cutler is now showing WA state's RX vs. illicit opioid mortality rates 1999-2018.

Short version: WA state's RX deaths started declining ahead of the rest of the country, in 2009. WA's illicit deaths increased at that time, but less that the rest of USA.

#WAOpioidTrial What happened in WA in 2009?

Washington State legislature passed the first opioid prescribing legislation in the nation in ESHB 2876, taking effect in 2010. Sponsored by a 30-year addiction counselor/legislator; supported by a local PROP board member.

#WAOpioidTrial 2009 was the beginning of the end of compassionate care in WA state. And the rest of the nation. It all started here, sadly.

Human Rights Watch did a whole report in Dec. 2018 with a special focus on WA.

hrw.org/sites/default/…

#WAOpioidTrial Sure enough - Dr. Cutler (well, the state) has put up a slide articulating the costs to the state. $9 billion alone in 2016

He breaks down:

Opioid-related deaths
Health care spending
Addiction Treatment
Criminal Justice
Lost Productivity

#WAOpioidTrial It would be interesting/compelling to get a commensurate slide for people w/pain putting an economic cost on:

Repeated medical appointments (different specialists, tests)
Insurance claim denial/appeals
Pharmacy battles/outages
Lost productivity
Pain &suffering

#WAOpioidTrial We are back from the PM break, and Dr. Cutler is asked about "Are opioid shipments causally related to the growth of opioid-related harms, including those resulting from prescription and non-prescription sources" and he says yes.

Here's the thing.

#WAOpioidTrial This paper - seems to directly refute at least SOME of that statement. The paper only addresses deaths, not harms - but the methodology is otherwise directly on point. ???

injuryjournal.com/article/S0020-…

#WAOpioidTrial "Washington state was ahead of the curve in addressing the opioid crisis in relation to the rest of the country." Because the shipments of RX opioids peaked in WA in 2009.

Yes. WA was ahead of the curve in attacking compassionate healthcare in the United States.

#WAOpioidTrial We are now seeing a map of USA w/diff shades of blue on each state to represent shipments of RX opioids on average 1997-2010. WA State is 2nd darkest (so lots).

No mention of total population. Number of disabled people. Surgeries. Traumas. Veterans. Seniors.🤷🏽‍♀️

#WAOpioidTrial One thing not in dispute: As the number of RX opioids decreased, the number of deaths from illicit opioids increased WILDLY.

No one ever mentions: Say, what happened to all those disabled people? Post-op patients? Trauma survivors? Seniors in pain? No one knows.

#WAOpioidTrial Let this be a lesson, folks: if you can measure it, you can bill for it. Sue for it. Write a narrative about it.

If it's something hard to measure? Like human suffering? Loss of productivity, quality of life?

Nearly impossible to measure and to get justice.

#WAOpioidTrial Dr. Cutler is referring to his charts and talking about all of the WA state efforts to decrease prescribing of opioids starting around 2008. Starting with: Medicaid limits (oh good. Start with poor people who have no ability to fight). Insurance limits. Etc.

#WAOpioidTrial Here's what I'm seeing: 99% of those people impacted by "the state's efforts to reduce prescribing" were NEVER going to develop an OUD. And how many of those millions of people SUFFERED FOR NO REASON?! And it saved no one. In fact, it made things more deadly. 😢

#WAOpioidTrial But since we can easily measure the number of prescriptions, certain people can CELEBRATE that lower RX number as a victory in the 'war on opioids'. They do not see the many, many patients and providers harmed by these actions.

#WAOpioidTrial I know it's not the point of this trial to get justice for pain patients, and for providers .... but man. NO ONE is factoring in the impact to people with legitimate medical needs and the people trying to treat their medical needs, who have been CRUSHED by this.

#WAOpioidTrial Back in the trial (sigh) - "Prescription Opioid Oversupply Directly Translates into Deaths from Non-Prescription Opioids".

People taking RX opioids they illicitly acquired switched to other illicit substances. Not just heroin/fentanyl - usually 4-5 substances.

#WAOpioidTrial Holy wow, Dr. Cutler made his OWN flow chart! I can't show it, obvs - but here's the 'responsible players' he identified:

Dispensers
Distributors
Manufacturers

Those all feed into "Excessive shipments".

Um. No mention of DEA? Prescribers? No ?

#WAOpioidTrial So apparently the Dispensers, Distributors, and Manufactures TELEPORTED 'excessive opioid shipments' directly onto the nation's streets, without any oversight or checkpoints or gatekeeping or, you know, anyone prescribing them.

Man. This flowchart is .. not good.

#WAOpioidTrial okay this not-great super simplified flow chart has been up for a WHILE. So I drew it! Here ya go. This is (apparently) all the players. Except for the ones not shown. 👀🧐

No, there is no way that this flowchart illustrates any illicit use prior to RX use. Or intermittent use. Or other-substance use prior to opioids. Or concurrent use. Or other variables which led to more illicit use. Nope, it's just this simple. Apparently?

#WAOpioidTrial Also apparently: If RX opioids had NOT increased in prescribing frequency (to appropriately treat undertreated pain in the USA which had left the medical community 'shaken'): we wouldn't have an illicit fentanyl/heroin/meth problem in WA today?

Whut? Srsly?

#WAOpioidTrial Dr. Cutler's showing a slide he made entitled 'Regression Analysis Establishes the Causal Relationship between Shipments and Opioid-Related Harms'

Basically: States which got higher numbers of RX opioids shipped had more harms than states with lower numbers.

#WAOpioidTrial Did he also measure benefits, perchance? People who survived surgeries, cancers, traumas with pain appropriately managed?

At what point does society determine that it is worth sacrificing appropriate pain management to try to avoid those potential harms? WHEN?

#WAOpioidTrial Dr. Cutler keeps saying "More pills = more harms".

It is not now, nor has it ever been that simple.

This entire assertion omits the need for pain care. Appropriate use. Addressing human suffering. I have no doubt his data is accurate. BUT LACKS CONTEXT.

#WAOpioidTrial You guys ... call me crazy ... but I think it may be possible that the state's very credentialed and articulate expert witness MAY just be showing us only the data which supports the state's position !

#WAOpioidTrial And just as we were about to ask Dr. Cutler a new line of questioning, a debate broke out about admissibility. It got complicated, so the Judge decided to call it for the day to review arguments and decide in the morning. And then ... .

#WAOpioidTrial As a last housekeeping measure defense raises that earlier they'd objected to a document during State's exam of Dr. Ciccarone as it was 'not on his reliance list'. State assured the court that it was, and proceeded. ONLY. Over lunch defense sorted out it WAS NOT.🤯

#WAOpioidTrial The lawyers for the state which said so this morning were not in the courtroom just now, so they're going to sort it out this evening and discuss it in the AM. If correct, they'll prolly strike some testimony?

Anyways - we're done for the day! Whew. Ciao!