Thread by @funchefchick

#WAOpioidTrial Day 26 is beginning this morning at this link.

We are starting with the arguments for/against striking all of former DEA's Ruth Carter's testimony (which was SO MANY hours). It's a defense motion to strike. Let's watch.

#WAOpioidTrial Defense says Carter missed a bunch of things, admitted on cross she'd never reviewed WA-state-specific things, etc. State is saying it was all finde etc. But the judge ... seems to be troubled about state's position on all this. Is he going to strike Carter?! 🤯

#WAOpioidTrial In a nutshell: 'Carter did not lay the proper foundation, did not do the proper research to CONCLUDE the things she stated categorically on the stand.' There were lots of holes. Expert witnesses are expected to seriously connect the dots. We shall see . .

#WAOpioidTrial Judge is striking SOME of Carter's testimony, keeping some. He has many serious concerns about the gaps/things she missed but says it doesn't rise to the level of striking ALL. What he's keeping - he'll consider those gaps 'as to the weight' of her testimony.

#WAOpioidTrial Judge is striking any of Carter's testimony regarding Ms. Keller's analytics - he remarked during state's arguments 'they were ships that passed in the night; they never met; no one reviewed/confirmed the algorithms for accuracy" etc. He seemed annoyed. So. Yeah.

#WAOpioidTrial And with that excitement out of the way, state's case continues with recorded deposition of a local longtime Cardinal Health employee, which they'd started last week. Depo from 12/17/2020. Asking about data and processes from at least 15 years before. Sigh.

#WAOpioidTrial Q to Cardinal employee on depo: "You once had a customer in a smaller community in a more rural area, do remember that?"

Witness: < . ... > Seriously, whut? Out of the whole state over decades?!

Also: He meant Forks, WA. Home of Twilight fiction. Seriously.🤦🏽‍♀️

#WAOpioidTrial Also, as a lifelong Washingtonian it isn't making any points when the interrogator does not know how to pronounce "Chinook". Sigh.

To be clear he also misspoke trying to say 'Forks', first. SERIOUSLY.

So yeah.

#WAOpioidTrial He also asks: "you agree with me that ultimately when it comes to anti-diversion policies it's to keep the public safe from very strong opioids"?

Weird. Shouldn't that be to ensure that people in pain HAD ACCESS TO their prescribed opioids AND keep others safe?

#WAOpioidTrial Apparently state's counsel believes that these defendants should have been keeping the people of WA so very SAFE from opioids that they'd be SAFE to the point of relentless agony and wishing for the relief of death.

Which, to be clear: state has succeeded at that.

#WAOpioidTrial Depo continued, yawn. We are now on the mid-AM break.

Still processing how judge's decision on Carter will impact the state's case. It seems it interrupts any alleged 'clear line of conduct' theories or analysis for the state. A lawyer would know! BRB.

#WAOpioidTrial State is wanting to call Dr. Moore (sp?) in person, but defense wants to argue about it first.

AmerisourceBergen's counsel is currently arguing before the judge about the why and what and such while the witness is excused from the court. Let's see what happens.

#WAOpioidTrial After some discussion about concerns and how to handle (presumed) objections, state calls its next witness (in person) Dr. Jakki MOHR. She's here to talk about marketing activities. She's a professor and PhD.
business.umt.edu/faculty-staff/…

#WAOpioidTrial Lots of describing the science and process of marketing, the roles/players involved, etc. etc.

As usual it is far more complex and nerdy than one would think unless one is an expert in the field. 🤔

#WAOpioidTrial Where we seem to be headed is that when Purdue was initially marketing OxyContin in roughly 1997, some of that marketing moved 'downstream' to distributors, who assisted in those marketing efforts (like w/other meds). TO PHARMACIES. Not to people in the street.

#WAOpioidTrial Again - whether pharmaceutical medications should be marketed - to doctors, to pharmacies, ON TV TO THE AMERICAN PUBLIC - that's a worthy discussion. Currently it's legal, within parameters. Trying to paint the 'marketing of opioids' as something unusual? 🤷🏽‍♀️

#WAOpioidTrial If you focus only on 'they marketed opioids' it sounds potentially problematic. But that's what pharma companies do, and have done, for a LONG TIME. That's capitalism. Welcome.

To now go back and say 'but they shouldn't have!' when there's no laws or regs?

#WAOpioidTrial To be clear: the *Manufacturers* marketed their meds. The distributors had an advertising channel in which the manufacturers participated. The distributors certainly never marketed RX opioids to patients (that I know of). Yet it's the distributors on trial here.

#WAOpioidTrial "Educating physicians about treatment strategies that reduce the risk of narcotic addiction may help address some of these physicians' concerns. Purdue may consider sponsoring pain mgmt conferences or lectures."

Those bastards? To safely treat PAIN? How dare they.

#WAOpioidTrial The manufacturers had pay-per-click advertising for OxyContin within a closed system; to pharmacists. Not the public.

No one has mentioned whether they did similar things for OTHER meds. I bet that they did though?

Again - we need the whole picture here, folks.

#WAOpioidTrial And the court has adjourned for lunch.

Trying to prove that the distributors 'more probably than not' caused a public nuisance in the state of WA . .. because of (legal) not-to-the-public marketing of
FDA-approved meds to pharmacies within a closed system? 🙄

#WAOpioidTrial And we are back - Day 26 continues this afternoon at this link. State (plaintiff) continues questioning their witness Dr. Mohr about pharmaceutical marketing practices.

#WAOpioidTrial Some (most?) of Dr. Mohr's testimony describes what she's called 'standard marketing practices; touchpoints w/different players in the ecosystem to ensure they are aware of who we are & the services we offer to lead to the desired outcome'.

So. Standard stuff?🤷🏽‍♀️

#WAOpioidTrial For clarity: Dr. Mohr seems super smart and is clearly an expert in her field. As with most of the state's witnesses, however - she's only been shown a small piece of a big, complex puzzle. She's using her expertise on that small piece. I have no issues w/Dr. Mohr.

#WAOpioidTrial "Dr. Mohr, do you have an opinion about whether the defendants participated in something you call 'segmentation analysis'?'

Dr. Mohr: Yes, I do; they did.

(Seems .. . ominous? What is it? Oh.)

investopedia.com/terms/m/market…

#WAOpioidTrial Now we are getting a Marketing 101 lesson about the "Four P's of Marketing". And whether the distributors - as part of the upstream efforts by Manufacturers, or as partners, or as contracted agents - participated in marketing. Of RX meds.

investopedia.com/terms/f/four-p…

#WAOpioidTrial State is using a document which says an opioid would be 'auto-shipped' to pharmacies which were 'high dispensers of similar meds' as bad?

The opioid was Butrans. They tried to ship a partial-mu agonist to pharmacies which dispensed lots of FULL agonist patches.

#WAOpioidTrial In English: Apparently they more-aggressively marketed a LESS addictive opioid patch to pharmacies to try to replace existing opioid patches. This would theoretically shift patients to a safer opioid product, for those whom it was as effective. IF prescribed.

#WAOpioidTrial Whether the Butrans patch was auto-shipped or not ... not a single one would be dispensed without a valid RX. From a DEA-licensed physician/ARNP.

But if they were - the patients would theoretically be safer on Butrans. This is not a good example of 'carelessness'.

#WAOpioidTrial ANYWAYS. State tenders the witness, and AmerisourceBergen's counsel is taking point on cross-examination on behalf of all of the defendants (although other counsel may also question as needed).

#WAOpioidTrial ABDC's first question: "your task in this case was simply to determine whether defendants engaged in marketing opioids, correct?"

Yes.

"You have no opinion that any of the defendants' marketing was false or misleading, correct?"

Correct. That was not my task.

#WAOpioidTrial ABDC (AmerisourceBergen) to Dr. Mohr: "You didn't look to see specifically whether defendants' marketing led doctors to write prescriptions that were medically inappropriate?"

Dr. Mohr: No, that was not in my scope.

#WAOpioidTrial ABDC: "You would agree that there are a number of different factors that might impact the sale of opioids, correct?"

Mohr: Yes certainly.

ABDC: "And some of those don't involve distributors?

Mohr: Yes certainly.

#WAOpioidTrial Aaaaaand a few other things after that. We are in the afternoon break at the moment, back in around 10-15 mins.

#WAOpioidTrial ABDC has been doing tons of "You're aware that the FDA regulates what marketing messages can be conducted, yes" Yep.

"You aren't offering the opinion that marketing prescription opioids should NOT be permitted by the FDA?"

Nope.

Dr. Mohr sounds annoyed.

#WAOpioidTrial "You are not aware which, if any, WA pharmacies actually received any of the marketing communications?"

Mohr: I mean these were nationwide campaigns. WA is *IN* the nation.

True. Also . . no.

(Mohr sounds increasingly MORE annoyed)

#WAOpioidTrial "You don't know if anyone from the state of WA ever attended continuing education programs or conferences you mentioned earlier? Or if they did, if it led to increased prescribing of opioids? Or medically inappropriate RXing of opioids?"

Mohr: Nope.

#WAOpioidTrial: "And you don't know if those continuing education programs led a pharmacist to fill any medically inappropriate prescriptions, right?"

Nope.

#WAOpioidTrial Oh wow - this witness just tipped their hand about how they REALLY feel. Wow. Hold please.

Q: "Taking an RX medication as it's been prescribed is following the doctors orders, correct?"

Yes.
' and following doctor's orders is a good thing correct?"

cont'd

#WAOpioidTrial Q: following doctor's orders is a good thing correct?

A: The integrated nature of this complicated industry makes it very difficult to say following the doctors' orders is correct . ..

🤯 But there's more.

Mohr: I'm sorry I just feel like as a parent if a DR prescribed my child to take 60 days of opioids I would say NO. So you know I can't say if the doctor says it we have to blindly follow it I would have great concerns with that we're talking about OPIOIDS not hypertension meds.

#WAOpioidTrial Ma'am, if a doctor TODAY said your child needs 60 days of RX opioids, then there is something TERRIBLY, painfully wrong with your child who would likely be screaming in agony. You sure you don't want to reconsider?

Plus: You can always discontinue them. Sigh.

#WAOpioidTrial Dr. Mohr IS getting annoyed.

Q: <this, right?>
A: Again I feel like taking each item out of context is difficult . .

Judge: At this point you just need to answer the question. The attorney for the state will have an opportunity to question you again.

A: Oh.

#WAOpioidTrial ABDC counsel: Hey this document about all of the marketing efforts you testified about earlier? I looked through it and it doesn't mention opioids even once.

A: Right I know this is a list of the services that ABDC offers generally for all of its products.

D'oh.

#WAOpioidTrial Anyway defense counsel started meandering a bit (IMHO .. I got distracted) and we ran out the clock for the day. Dr. Mohr will be back in the morning at a minimum for redirect, but I suspect defense will have some more cross to finish first.

And we're out!

@summarizethread compress