Thread by @funchefchick

#WAOpioidTrial Day 27 is starting at this thread. Yesterday's trial day ended w/Dr. Jakki Mohr, Marketing expert/professor/Doctorate/wizard somewhat defensively arguing about opioid manufacturing/distributing marketing practices. Cross by McKesson starts

#WAOpioidTrial McK: "All marketing activities you described were conducted for ALL products, not just opioids, correct? Many different products beyond opioids. We gotta fill pharmacy orders across all products, right?"

Mohr: Yes.

#WAOpioidTrial Dr. Mohr previously served as an expert in a case against Purdue by the state of Montana.

Interesting. McKesson is attempting to introduce the State of WA vs. Purdue lawsuit.

This suit. 🤔

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#WAOpioidTrial Judge is admitting - over the objection of the state - the lawsuit. Fascinating.

The suit states (pg 6) that Purdue's marketing campaign re: opioids was deceptive. McKesson's counsel asks Mohr if she's aware this was an admittance. (?)

Pointing the finger?

#WAOpioidTrial McKesson's counsel seems to be saying: look, if Purdue admitted wrongdoing UPSTREAM then surely any guilt/liability/responsibility involving marketing activities lies with Purdue (the manufacturer) not with the distributors. Mohr is resisting agreeing so far.

#WAOpioidTrial The judge has been overruling most of state's objections to this line of questioning but the judge just sustained one raised by state saying: "I've given you a fairly long lead; you've just reached the end of it."

I'm a fan of the judge, in case that wasn't clear.

#WAOpioidTrial McKesson successfully introduces on the record this article specifically this bit.

The point being: manufacturers marketed directly to prescribers in the millions. Surely that led to more prescribing than distributors -> pharmacies?

ncbi.nlm.nih.gov/pmc/articles/P…

#WAOpioidTrial And now this. McKesson is indeed illustrating that the manufacturer's budget & efforts to market opioids were orders of magnitude larger than any distributors and were directly to the 'ultimate gatekeepers', not to pharmacies. Seems legit.

ncbi.nlm.nih.gov/pmc/articles/P…

#WAOpioidTrial Dr. Mohr's stripes are showing. When shown a statement: "Educating physicians about treatment strategies that reduce the risk of narcotic addiction may help address some of these physician's concerns"

Her response is: I think it needs to be placed in context.

#WAOpioidTrial When asked again she replies:

Mohr: 'I'm concerned that this is one sentence in four sentences and taking it out of context is misleading'

Asked a third time: 'I mean what you're reading is read accurately.'

It seems Dr. Mohr is firmly on the anti-opioid team.

#WAOpioidTrial Interesting. McK is referring back to earlier marketing programs introduced by state on direct, and says: "You have no proof that McKesson ever actually conducted this/these campaigns?"

Mohr: Correct.

Hmmm. So earlier they only DISCUSSED possible campaigns?!

#WAOpioidTrial McK: "This email about e-vouchers was internal to Purdue employees only, and there's no proof that McKesson ever even saw it, correct?"

Mohr: Correct.

😮

#WAOpioidTrial The hits just keep on coming like that - McK: "This email internal to Purdue saying McKesson was requesting a grant to fund continuing education at a conference .. no proof it actually happened?"

Mohr: No.

#WAOpioidTrial McK asks Dr. Mohr about her Butrans testimony. He asks if she's aware that it is not a Sched 2 opioid. She says no, she's not.

She's testified to a lot about opioid marketing but does not know the difference between sched 2 vs 3 opioids.
Seems problematic.🤔

#WAOpioidTrial WOW. Once again, Dr. Mohr makes a couple VERY biased statements out of nowhere on cross.

McK to Dr. Mohr: You're not saying there's anything wrong with programs encouraging people to take their RX meds as prescribed by their doctors, right?

cont'd

#WAOpioidTrial Mohr replies: "I did state yesterday on this question that when we're being asked to stay on opioids for a long period of time I think that's highly questionable if the doctor has made a medical judgment . .. "

????

#WAOpioidTrial McK asks: "You're saying you still think that medical judgment is highly questionable?"

Mohr: "As I said if it was my doctor prescribing for my kids to stay on opioids I would question that."

Why would kids need to 'stay on opioids' unless truly suffering?! 🤦🏽‍♀️

#WAOpioidTrial Anyway. McKesson's counsel wrapped that up by introducing a transcript from an earlier trial where she was asked 'there's nothing wrong with adherence programs, right?' and she said no.

Today, however, she said about her earlier answer:

#WAOpioidTrial Mohr: Yes I have to say that it was the first time I had testified, and it is an intimidating environment.

McK: It was true and accurate when you gave the testimony, correct?

Yes.

I mean - is she now saying it is BAD to encourage people to take meds as RX'd?!

#WAOpioidTrial Anyway we are in the mid-AM break now, and Cardinal had just begun their cross-examination of Dr. Mohr briefly just before the break.

Each defendant gets to ask company-specific stuff about her testimony, is why. Back in a few!

#WAOpioidTrial We're back. Cardinal is doing similar things: "All these docs you testified about re: Marketing - no proof Cardinal was ever notified about them, OR that they ever happened?"

Mohr: Correct.

'This one was a meeting invite to a conf call, not a contract?'

Yep.

#WAOpioidTrial Plus Cardinal did marketing stuff for NON-opioid meds ..like tons of it.

But that's not how it was portrayed earlier. At all.

Cardinal is showing evidence that various mktg programs NEVER included opioid meds. Well. Derp.

That's not a good look for state.🤦🏽‍♀️

#WAOpioidTrial CH: "You have no evidence that <any of these marketing programs you testified about> involved opioid medications, correct?"

Mohr: "I have no evidence of that."

Like .. . she testified yesterday that there was tons of marketing campaigns for ALL meds incl opioids.

#WAOpioidTrial Heh. Cardinal is clarifying that the only marketing for a savings card conducted re: opioids was for Buprenorphine, and for Butrans.

Dr. Mohr says that she "cited it as evidence of savings programs for an opioid".

A sched 3 opioid. Mainly for MAT. But sure?

#WAOpioidTrial To sum up: WA state seems to believe that marketing a partial-mu agonist like Bupe or Butrans - widely acknowledged by just about everyone as a far safer version of meds to treat pain OR addiction - is a damning example of defendants' creating a PUBLIC NUISANCE.

#WAOpioidTrial For anyone just joining us: that marketing was mainly to PHARMACIES, not to patients. Or prescribers.

And most examples cited by state were simply planning or discussions of potential marketing efforts - not ACTUAL campaigns. Plus no tie to increased RX'ing.🤷🏽‍♀️

#WAOpioidTrial So far Dr. Mohr has been an expert witness in WV, SC in the MDL, and will appear in WA vs. Johnson & Johnson, suit here. Anyone else wondering how much $$ she's making on these trials? I sure am.

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#WAOpioidTrial Also the state has raised a series of annoyed objections about the current line of questioning and the judge keeps overruling them and it seems like EVERYBODY is getting increasingly annoyed.

Don't tick off your judge, folks. Pro-tip. 😬

#WAOpioidTrial Yep. Dr. Mohr gave a long, meandering, not-responsive answer . . . and indeed it was stricken as non-responsive.

Her bias is shockingly clear now.

#WAOpioidTrial Cardinal wrapped up after a couple of contentious objections, and state will now begin redirect.

Very curious to see where this will go after all of THAT.

#WAOpioidTrial Of all things . .. state starts asking Dr. Mohr about Butrans and Bupe. Does she know what they are for?

Mohr replies that she is not a medical doctor.

Butrans is prescribed for pain severe enough to require daily, round-the-clock care ... etc. Not MAT.

#WAOpioidTrial State wants to make it clear that Butrans is for pain, not addiction care. So that marketing efforts for it were still ... somehow bad?

Does the state of Washington NOT understand what a partial agonist medication is? And why it's different? Sched 3?!

Seriously?!

#WAOpioidTrial State is focusing AGAIN on Butrans.

I just ...

Mohr repeats that it's important for products to be available in the supply chain for people acquire them later. AFTER A PRESCRIPTION IS WRITTEN.

It does not matter if Butrans was stacked to the sky; no RX? No med.

#WAOpioidTrial State of WA is quoting state of WA's own lawsuit against Purdue and reading it into evidence, asking Mohr to agree with the statements. IN THE LAWSUIT COMPLAINT.

Which, of course, she does. She's being paid to, of course.

(Allegedly)
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#WAOpioidTrial Bummer. Mohr went off on her own rant against opioids and eventually ABDC's counsel tries to object - but the judge overruled. It really was a long rant with her personal opinion. She keeps saying, "I feel like I'm asked .. "

#WAOpioidTrial Ha - state's witness' tendency to meander bit state in the butt. State asks as a wrap-up question: "Did anything defense asked you on cross change your mind on things?"

Mohr: <long meandering answer>

State: D'oh. Lemme re-ask that.

#WAOpioidTrial Mutiple defense counsel raised some strong objections at the end there - all overruled.

State's done, we're on re-cross now. McKesson starting.

#WAOpioidTrial And in a funny moment, McKesson asks Mohr about 'how many years later was this report' and asks was it 15, she says no it was BEFORE not later, and the judge accurately points out that it was FIVE not 15 ... and the court all laughs and says can we have lunch now?

#WAOpioidTrial Anyway we're all done with Mohr. No further re-cross.

State pulls up a recorded depo from May 10, 2019 to use up the last ten mins before lunch.

It's this guy: hda.org/persons/patric…

#WAOpioidTrial Aha. The whole point of this depo is to introduce a document. Only there's now a lot of debate about this document and whether it is the final version, etc.

Judge is going to review stuff over lunch it looks like.
Previously he did not allow an earlier version.

#WAOpioidTrial This is all about the HDA document, btw. Industry compliance guidelines which we heard about earlier in the trial, the morning of 1/27.

And on that note: it's lunch! Back at 1:30pm PT.

#WAOpioidTrial We're back for the afternoon at this link. Judge ruled to accept that HDA document, after reviewing all the things.

State calls its next witness: a local City of Seattle employee who knows about sharps disposal and stuff.

#WAOpioidTrial It's a person who manages reports from this Seattle app, which - it appears that 'report a found needle somewhere' is part of the categories listed.

Which is interesting. But RX opioids almost never involve needle use . . . so ... ?

seattle.gov/customer-servi…

#WAOpioidTrial WA is spending a ton of time filtering a very large spreadsheet looking for how many times 'needle' appeared in these reports for the City of Seattle in a given year.

Which illustrates things like:
Heroin/Illicit Fentanyl
Cocaine
Meth
Ecstasy
Ketamine
PCP

#WAOpioidTrial How will WA tie illicit drug use (illustrated by needles found w/in the city of Seattle) to *distributors* of legal, pharmaceutically-produced opioid pills which were prescribed by medical providers?

I do not know. They've collapsed ALL opioids this whole trial.🤷🏽‍♀️

#WAOpioidTrial Yep state focused all their questions on quantity and frequency of needles found within Seattle. That's it.

State tendered the witness, and Cardinal is taking point on cross.

#WAOpioidTrial Cardinal quickly points out: the city does not test found needles to see how many were opioid vs non-opioid, vs insulin. Or changes over time.

They do not.

CH asks if these needles collected could be distributed from needle exchange programs. He doesn't know.

#WAOpioidTrial CH asks the witness if he know about methamphetamine use, or cocaine in those needles.

He does not know. And that's it. No redirect, witness is done. Off he goes!

#WAOpioidTrial State calls its next witness: Dr. Caleb Alexander, Pharmacoepidemiology at Johns Hopkins. That's how he identifies his specialty, but he's got lots of choices: publichealth.jhu.edu/faculty/2761/c…

#WAOpioidTrial Oh dear. I don't know Dr. Alexander, but he co-authored a document with Kolodny back in 2015 which he's listed on his 'selected publications related to opioids' document list.

That's not a great sign. 😳

#WAOpioidTrial Dr. Alexander has testified in multiple opioid trials, including WA vs. Purdue apparently. And WV. Where he said:

'“It’s an opioid epidemic,” said Alexander. “Prescription opioids and heroin and fentanyl are two sides of the same coin.”

mountainstatespotlight.org/2021/07/02/wha…

#WAOpioidTrial If I had to guess, his testimony is going to look like this (someone live-tweeted the WV trial, it looks like!):

https://twitter.com/HesslerHD/status/1409512223635083265?s=20&t=JVizPYgkxS0PsJJ1uVttHA

#WAOpioidTrial And we're in the mid-PM break for 15 minutes. Stay tuned. !

#WAOpioidTrial Alexander: "Among the programs he highlighted, he said doctors need to be educated by a non-biased source who can better teach them how to RX pain pills. Specifically, the county's top opioid RX-ers who RX disproportionately should be singled out and re-educated."

#WAOpioidTrial Dr. Alexander has an abatement plan to fix the overdose crisis, and all he needs is billions of dollars.

I will be eager to hear how he will address the millions of people with severe, chronic pain and their lack of access to medically-appropriate care.👀

#WAOpioidTrial "I am aware of many studies already I'm just coming to - you know- I have knowledge of many studies that are helpful in that they may serve as seminal studies for example a study that looked at the impact of providing people that come into an ED w/OD with Bupe." 🤔

#WAOpioidTrial Apologies, I've been horrified while reading various quotes from Dr. Alexander in different articles and such.

He's here to talk about 'abatement programs' - he can give us a plan to solve the opioid crisis here in WA and it will only cost billions. No mention..

#WAOpioidTrial No mention of the current resurgence of methinvolved overdoses, or HOW one does all this without further harming people with EVERY type of pain (acute, surgical, chronic, cancer, end of life) as well as their providers? So far he's talking re-education. <shudder>

#WAOpioidTrial Hey you guys. Dr. Alexander says that people with addiction should be treated with dignity and compassion. !! We never would have thought of that!

Also: No mention of how people with incurable, intractable pain should be treated so far.

#WAOpioidTrial Lots more content about recovery and treatment. I have no problem with investing in more treatment and recovery programs; fully support!

I'm not sure how the distributors can be found to be on the hook for the costs, however.

Still no mention of pain care.

#WAOpioidTrial Those experiencing homelessness are at much higher risk of OD, and greater Seattle has a terrible & ever-increasing unhoused population.

Is Dr. Alexander (and the state of WA) expecting pharmaceutical distributors to foot the bill for solving the unhoused crisis?

#WAOpioidTrial The state plans to spend another hour or two on Dr. Alexander tomorrow, and then some cross and stuff.

And that's it! Day 27 is a wrap. Ciao!