Thread by @funchefchick

#WAOpioidTrial Day 28 beginning. Random thought: Are bench trials far more stressful for judges than jury trials? In a jury trial judge has to make sure the jury hears appropriate/admissible evidence, then jury decides. Bench must do same AND then rule.?

#WAOpioidTrial Regardless, we resume with the state of WA and their witness Dr. Caleb Alexander . .. notoriously PROP-affiliated, anti-opioid, 'everyone using opioids for pain is at risk of addiction' doctor who is here with a plan to 'abate' the epidemic in WA. Sigh.

#WAOpioidTrial To be clear: people in the know in WA are reasonable and appropriate. The Washington Medical Commission. The WA Dept. of Health. Assorted agencies. They recognize that people in pain deserve individualized care and that providers should be protected/encouraged.

#WAOpioidTrial I seriously fear that my state AG's office does not know or does not care how many state residents have been harmed by the vitriol & bias of this witness; & by their office's actions. There are hundreds of thousands of us in WA who DO know and do care. And we vote.

#WAOpioidTrial State has Dr. Alexander describe the first page (only) of a big, detailed spreadsheet and then tries to admit the entire workbook. Defense (rightfully) objects to tons of pages not discussed or reviewed going on the record. Judge sustains. State's trying again...

#WAOpioidTrial Dr. Alexander is vehemently stating how critical it is that people with OUD get *individualized* care according to their needs.

Yep. That would be great. Everyone should always be getting that.

Including people with pain. All kinds. Including chronic pain. 🤯

#WAOpioidTrial Dr. Alexander is just detailing all of the different categories/costs of his 'abatement plan' for WA state that HE developed. At the behest of the state AG.

I wonder how the addiction specialists of WA state feel about this plan? Has anyone local vetted this?

#WAOpioidTrial We are spending a ton of time talking about the billions of dollars and extensive plans and programs we need to address the 'opioid crisis'.

As one of the 5x more people with severe, chronic pain who have been ignored by MANY during this 'crisis': I'm angry. 🤬

#WAOpioidTrial Literally Dr. Alexander - looking for a parallel for treating OUD: "Like with mental health, we don't just put someone on an anti-depressant for two 1/2 months and say you're good to go."

But some do. With anti-depressants for pain. They really do. Doesn't work.🤷🏽‍♀️

#WAOpioidTrial Ha. State/Alexander is discussing an article from JAMA open which he co-authored, and quite a bit.

OH. Hmm. Anyone else worried about bias? Anyone?

jamanetwork.com/journals/jaman…

#WAOpioidTrial Hey don't worry folks! The plaintiff attorneys (who have been paid more than $2 BILLION for these opioid trials) who asked for this model didn't IN ANY WAY influence it. The model they used to win those lawsuits. To make those billions.

Nothing to see here ...

#WAOpioidTrial Now we're looking at the 'Apollo' model they created, which is here. Ony the version they are showing in the courtroom? The box in blue is ALL BLACK. OMINOUSLY. RX opioids . . . routinely end in heroin and death. (No, they don't.) 🤯

pubmed.ncbi.nlm.nih.gov/33146732/#&gid…

#WAOpioidTrial Anyway, this model WHICH WAS CREATED FOR THE OPIOID TRIALS is elaborating all of the possible pathways of opioid use disorder treatment; cool. Except ..

From a prohibition model. I have not heard Dr. Alexander say 'harms reduction' even once, I don't think. 🤔

#WAOpioidTrial State: Why did you call the model Apollo?

Alexander: Well you know Apollo was an Olympian deity & among other things the God of health & disease & truth & prophecy & of course there was a space mission named Apollo & it occurred to me that that would be fitting

#WAOpioidTrial Ahem. 😠

Anyway we're on the mid AM break, or just about the end of it for accuracy.
greekmythology.com/Olympians/Apol…

#WAOpioidTrial Alexander, looking at a chart: "as you can see the effects of just reducing prescribing (on reducing deaths) are modest here and that's partly because of the years that we're looking at"

But mainly because >90% of people prescribed opioids never misused them. 🤔

#WAOpioidTrial In case it wasn't clear: Alexander has been talking ad nauseum about his abatement plans.

It never mentioned how to care for people with pain (then or now).

It never mentioned how RX opioids are used safely every day, every where, all over the world.

#WAOpioidTrial And it certainly never mentions that the overwhelming majority of overdose deaths in WA state (like most of the nation) involve methamphetamines along with heroin/illicit fentanyl.

It almost NEVER involves any kind of prescribed medication. 🤷🏽‍♀️

#WAOpioidTrial <Later ... that same day .... >

Dr. Alexander is continuing to go on and ON about 'row 16 in year 15 for ages of adolescents 12-15' and I'm HEY what's that shiny thing over there?

#WAOpioidTrial In which we learn that NO, Dr. Alexander did NOT include any non-opioid substances in his 'model'.

When more than half the state's overdoses involve meth. Good job there, buddy. Super-helpful.

#WAOpioidTrial Sigh. Dr. Alexander insists that we STILL have an 'opioid epidemic' not an 'overdose crisis'. Hey how about mentioning polypharma overdose the BIG problem we face?

Like nearly ALWAYS.

#WAOpoidTrial Oh hey now Dr. Alexander IS talking about stimulants and polysubstance use.

He's just (apparently) saying that opioids are main/only thing we need to worry about. I guess?

pubmed.ncbi.nlm.nih.gov/33511987/

#WAOpioidTrial Alexander: 'so as we reduce the oversupply of opioids & the over dispensing & overuse of opioids in clinical practice the reservoirs that are in people's bathroom cabinets & bedroom you know that reservoir will decline'

He sees reservoirs. I see people w/pain.

#WAOpioidTrial Literally people w/chronic pain SHOULD have their RX opioids on hand to treat their crippling pain. As should people with acute or cancer or end of life pain.

All this talk of 'drying up the reservoir' of RX opioids in med cabinets: what happens to people w/pain?

#WAOpioidTrial BTW the state tendered the witness (finally) and McKesson's counsel is taking point on cross.

He's starting with "you never indicated in your model those who never took an RX opioid"? Meaning: Most of this math? Does not apply to RX opioids. Or defendants.

#WAOpioidTrial Things were getting a little heated there in the courtroom just now.

Defense: "You didn't calculate X, did you?"
Alexander: <opines for some time about the best ways one could calculate that thing he didn't include in his report>

Defense: 😕

#WAOpioidTrial Defense: "Uh - I asked you a very narrow question."

Alexander: < . >

Anyway there were some heated objections and debate then the judge decided it was time for the lunch break anyways. Good call, judge. Back at 1:30pm PT!

#WAOpioidTrial We're back at this link for the afternoon. Starting/some housekeeping discussions about the order of things; with a trial this long & complex & with multiple defendants the order of witnesses, cross-examinations, and summations is tricky.

#WAOpioidTrial We resume cross-examination of the pedantic Dr. Caleb Alexander by McKesson's counsel.

And immediately the state raises an objection, which is overruled. And then the state tries to keep arguing it.

And the judge re-overrules.

#WAOpioidTrial Alexander: "My work isn't to figure out the genesis of the opioid epidemic or who is responsible in causing it."

Um. It sure seems like understanding THOSE things would be super-helpful at figuring out how to address things.

Read the room, doc.

#WAOpioidTrial Mck: 'Was that testimony true and correct when you gave it?

Alexander: Well I don't have reason to believe my testimony then was not the truth but my testimony at that time was my belief and you know without reviewing the material carefully including . .. (cont'd)

#WAOpioidTrial Alexander, cont'd: carefully including Apollo output I think I would want more time to confidently assess the relative size of populations . . .

Me: 👀 So that's ... a yes? WTF?

#WAOpioidTrial I am beginning to wonder if Dr. Alexander is being paid by the word.

Or does he just like to hear himself talk? 🤷🏽‍♀️

#WAOpioidTrial McK: You say here it should be left to WA to decide about <stuff>, yes?

Dr A: well you know I I as an expert advising the court I I don't feel that it's my place to use language that's stronger to suggest the imperative of a certain suite of programs or services

#WAOpioidTrial Dr A, cont'd: so this is my effort to say that I offer this as my judgment and my recommendation but I leave it to others to decide ultimately how to proceed again in part because I'm an expert and in part because time will endure and (cont'd)

#WAOpioidTrial Dr A STILL CONT'D: and what this looks like in in 2023 the services and programs and levels of these may look different than they look today.

To recap: He was asked a yes/no question. 🤦🏽‍♀️

#WAOpioidTrial McK's questions continue along the line of: Dr. A didn't bother to research what WA state already has in place for treatment options, or how they are funded, or whether there are sufficient resources, etc. etc.

He did not do any of that. But he has A BIG PLAN.

#WAOpioidTrial Which - apparently that BIG MANY BILLION $ PLAN will work for any state, any populations, any substances, & regardless of what existing treatment resources are in place or in the works & regardless of regional or geographic variations.

That's AMAZING! </sarcasm>

#WAOpioidTrial We're back from the PM break with more McKesson cross of Dr. Alexander, but I gotta step away for a bit - I'll try to wrap up the rest of the trial day from my notes later. 🤞🏽

#WAOpioidTrial To recap the end of the day: Dr. A agreed he wasn't blaming defendants, or criticizing their handling of suspicious orders, or requiring any changes to their business practices. Nor did he differentiate AT ALL between illicit and RX opioids for ANYTHING. Sigh.

The more interesting bit at the end of McK's cross: Dr. Alexander has provided these reports in 7 opioid cases. His company - Monument Analytics - has been paid $6 million for trial reports as of last summer. Dr. A bills for this trial work personally at a rate of $900 per hour.

Dr. A used to own 100% of Monument but now owns only 65-75% he estimates. (He also makes around $225K per year in salary at Johns Hopkins). He'll have pocketed between $3.9 million to $4.5 million in OPIOID LAWSUIT money (65-75% of $6m).

Well. I wonder what his motivations are?

#WAOpioidTrial THAT IS CORRECT. Yet another expert witness is pocketing MILLIONS of taxpayer dollars on these opioid lawsuits. Literal millions.

To tell judges that RX opioids caused the overdose crisis. And that manufacturers, distributors, pharmacies and doctors did too.🤦🏽‍♀️

#WAOpioidTrial Other things we learned today: Despite using NSDUH data in all of his models, when Dr. Alexander was shown NSDUH data showing a decline in opioid death rates in WA he reacted angrily saying "You can't trust NSDUH data, it is notoriously inaccurate/inconsistent'. 👀

#WAOpioidTrial Mck: You're aware that illicit fentanyl is causing far more harms than heroin today, correct?

Dr. A: They are both huge problems. I mean they are massive problems.

McK: But Illicit fentanyl is more than heroin, though?
Dr. A: Heroin often has fentanyl in it.

#WAOpioidTrial McK: Okay but LITERALLY here in WA illicit fentanyl is a bigger problem than heroin and the heroin in WA doesn't usually have fentanyl in it, according to the data?

Dr. A: Well, yes.

SIGH. Was that so hard?!!

#WAOpioidTrial I am sad to report that Dr. A will be back on the stand for more cross tomorrow morning.

And that wraps up today's coverage of trial day number . . . what are we on again? Day 28! One more day of trial this week ... we can do it .... !