Thread by @funchefchick

#WAOpioidTrial Day 29 is starting at this link.

OH HEY did anyone else notice that the CDC released their draft of their REVISED opioid prescribing guidelines this morning? BECAUSE THEY DID.

Any impact on the trial? Dunno.

painnewsnetwork.org/stories/2022/2…

#WAOpioidTrial Aaaand after some housekeeping measures, McKesson's defense counsel resumes their cross of Dr. Caleb Alexander ... . PROP affiliate. Good times, good times.

#WAOpioidTrial McK: In your report you said 'rogue MDs and 'doctor-shoppers' account for only a small amount of harms, right?

Dr. A: <long meandering paragraph which doesn't answer the question>

Courtroom: 🙄

#WAOpioidTrial McK: In an earlier trial you said that most doctors weren't RX-ing for bad reasons, weren't pill-mills, they were trying to help their patients and do their job?

Dr. A. I dunno.

McK: See this exact quote in the transcript where you said that?

Dr. A: Oh. Yeah. 👀

#WAOpioidTrial McK: See here where earlier you said that 'opioid shoppers' accounted for 0.08% of individuals filling opioids, and 0.42% of total opioid volume?

Dr. A: Yeah but we defined it ...differently ... and stuff.

🙄

#WAOpioidTrial McKesson wrapped up cross shortly after that last one - he was moving pretty fast, it was hard to keep up! No other defendants wanted a crack at Dr. A on cross.

State is up for redirect. Please gods let it be brief.

Reminder: Dr. A has made ~$4mill for this.😠

#WAOpioidTrial By the way: Dr. A has mentioned his pet project, the "Apollo" abatement plan - like SO MANY TIMES. It's his baby. His company has made more than $6 million producing it. He's still hyping it in this trial EVEN NOW.

Again, a few more times just now, on redirect.

#WAOpioidTrial For the love of all that is holy they opened up that massive spreadsheet again on redirect.

As a person who worked at that big tech place where they make spreadsheets (and other things) I'm begging: STOP.

Oh great, now we're on tab 22A, column N. It's riveting.

#WAOpioidTrial Later, same day:State is still conducting redirect on Dr. A.

In a funny moment defense just objected: I don't think it is proper usage showing Dr. A his OWN PRIOR TESTIMONY via transcript and asking if he remembers it.

Judge: Def SUSTAINED.🤣

Judge❤️efficiency!

#WAOpioidTrial Oh, the irony. State is showing this, co-authored by peeps who co-authored stuff with Dr. A.

What does Dr. A say? 'these are very knowledgeable folks; they are looking at using NSDUH data to understand people using RX opioids nonmedically'

jamanetwork.com/journals/jamai…

#WAOpioidTrial BUT WAIT. Didn't Dr. Alexander JUST YESTERDAY dismiss the NSDUH data as wholly unreliable, when that data said things he did not agree with? On the stand? Oh yes. He absolutely did. D'oh.

https://twitter.com/funchefchick/status/1491611004022636544?s=20&t=tKUsW1aa7GBHRyzqGmzJ9A

#WAOpioidTrial Quote from Dr. Alexander:"I think that the stockpile of medicines in our own houses reflects the volume of medicines prescribed and FAR TOO MANY FAMILIES AND HOMES HAVE OPIOIDS SITTING AROUND."

People in pain taking RX opioids as RX'd have them at home, ya jerk.🤬

#WAOpioidTrial Not to mention: The AMA issued a report today showing a 44.4 percent decrease in opioid prescribing nationwide in the past decade. At the same time the country is facing a worsening drug-related overdose and death epidemic.

Good job, PROP.

ama-assn.org/press-center/p…

#WAOpioidTrial We're back from the mid-AM break, and after state introduced a handful of docs into evidence (no objections from defense) they call IRL witness Dr. Jeffrey Liebman, from Harvard.

govlab.hks.harvard.edu/people/jeffrey…

#WAOpioidTrial 'Former Chief Economist for the U.S. Office of Management and Budget Dr. Jeffrey Liebman put the cost of opioid abatement in Washington at $38 billion over 15 years'

courthousenews.com/trial-begins-i…

#WAOpioidTrial Interestingly, in California defendants moved to exclude Dr. Liebman's estimates for abatement in their 'public nuisance' trial . .. I don't know what happened there.

static.reuters.com/resources/medi…

#WAOpioidTrial Also isn't Harvard in the news this week for something terrible?

Oh that's right. See specifically the 'Notes From a Private Therapist' section. It's bad. REAL BAD.

insidehighered.com/news/2022/02/1…

#WAOpioidTrial Aha - it seems Liebman has also testified at multiple opioid trials, just like Alexander. Heck WITH Alexander. See this from the MDL: govinfo.gov/content/pkg/US…

#WAOpioidTrial While Dr. Liebman explains his lengthy bonafides, I searched for where his name appeared along with "opioid"; like this one. In particular I was interested in Exhibit R: Attorney's fees.

attorneygeneral.gov/wp-content/upl…

#WAOpioidTrial We already know that Motley Rice (hi, plaintiff counsel!) are getting paid ~$2 billion from the MDL settlement ALONE.

I dunno what the above table is from - perhaps it's part of that? Regardless, the $ in the Attorney Fee fund adds up to $1,292,307,692.47.🤯

#WAOpioidTrial Regardless: It is crystal clear that the people benefiting the MOST from the #LitigationNarattive is the lawyers. Mainly from Motley Rice. They are earning BANK and none of that money is helping those with OUD, or SUDs, or pain, or their families who lost them.

#WAOpioidTrial If anyone can tell me how to find out how much of WA state's taxpayer dollars are being spent on this ridiculous trial, hit me up in my DMs. I emailed the AG's office in December to ask them, and they have not responded. 🤔

#WAOpioidTrial You guys . .. I know that you will be thrilled to learn ... WE ARE LOOKING AT ANOTHER MASSIVE SPREADSHEET! w00t!

Tab 5, column C, row ... oh who hell cares. I'm getting more coffee.

#WAOpioidTrial Oh hey after still more spreadsheet review into various things ALMOST ENTIRELY UNRELATED IN ANY WAY TO RX OPIOIDS FOR PAIN DISTRIBUTED BY THE DEFENDANTS . . . it's time for lunch. Thank the gods.

#WAOpioidTrial Okay but real quick - a minute ago the Dr. said "4% of WA tenth graders report using 'pain relievers to get high" and then went on with his number.

Hmm. What's that from? I hadn't heard that before.

Long story short, it's from here: askhys.net

#WAOpioidTrial So I pulled up the fact sheets for 10th graders for all types of substance use. Here's the facts. They asked a small group of 10th graders about the previous 30 day's use, back in 2018. Can we not get more thorough, recent, credible data? Also: Kids is drinking.😬

#WAOpioidTrial To recap: state is saying that 4% of the WA's 10th graders are 'using pain killers to get high'. When in reality they polled a small group of students, asked them about what drugs/alcohol they'd used in the past THIRTY DAYS, and now that's official for the state.

#WAOpioidTrial We're back, day 29 cont'd this PM at this link. Dear Santa: I have been very good this year. Please limit the number of minutes this trial continues to spend on tedious spreadsheets which don't acknowledge the need to treat pain. Kthxbai.

#WAOpioidTrial For clarity: we are reviewing the theoretical cost of 'abatement' for the 'opioid crisis' in WA from experts not from WA who have done no research into existing treatment frameworks or costs. Soo. Yeah. Also: No differentiation of illicit substances vs. RX. So.🤷🏽‍♀️

#WAOpioidTrial Also we are reviewing all of these estimates and abatement plans (AGAIN, based on ALL opioids where *OVERWHELMINGLY* it's illicit opioids causing overdoses here and everywhere) as if the distributors of legal, prescription medications had any accountability for it.

#WAOpioidTrial Sidebar: The Emperor's New Groove was a pretty great movie which doesn't get enough raves and credit all these years later.

Squeak, squeakin', squeak, squeakity!

#WAOpioidTrial Surprising literally no one: more spreadsheets.

They are literally having the Former Chief Economist for the U.S. Office of Management and Budget read out the number values from various cells on many, many pages of spreadsheets. 🤦🏽‍♀️

<whimper> For 20 mins now.

#WAOpioidTrial I wish I were kidding. They're asking the witness to read out the projected costs of various programs, by year for each year from 2021-2035. We're on the 11th row. With 15 values each (1 per year). He's read out 165 values, each one in the millions. Plus totals.

#WAOpioidTrial Why did I do that math? BECAUSE this witness has at least <checking screen> 10 more rows (or 160 more values, each in the millions) to go. This will take some time.

"Could you read the cost of <program> for every year from 2021-2035? Plus the total?" Sigh.

#WAOpioidTrial Oh thank goodness. State: "Is this plan tailored toward addressing the opioid crisis?"

Witness: Yes.

(I mean, it's HIS plan, so yeah.) Also: YES. People with OUD absolutely SHOULD get appropriate care.

Do you know who else should? People with PAIN.

#WAOpioidTrial So his plan will cost $35 billion over the next 15 years.

State keeps trying to ask if "it is appropriate to spend that" and witness compared it to other programs. Defense objected - other programs were not mentioned or disclosed. Judge sustains.

#WAOpioidTrial State tries to end-run around the objection/ruling, and defense raises it AGAIN.

Judge: It seems you are trying to evade my previous ruling by coming at it from a different direction; my ruling stands. 👀

Ooooooo.

#WAOpioitTrial AND THEN state tried it a THIRD time. Judge called him on it AGAIN.

Counsel apologies profusely to the judge.

The judge remains silent.

Oooooo.

#WAOpioidTrial Heh. So .. . state was pretty much done with the witness but wanted to check with co-counsel before tendering. "Of course" says the judge.

Counsel returns: Would now be a good time for the afternoon break?

Judge: Not if you're not done. We go until 2:40.

#WAOpioidTrial Judge: If you ARE done, we'll break now & resume with cross.

Basically: State was trying to buy time to huddle & strategize before tendering the witness. Our judge saw RIGHT THROUGH IT and said nope. Also Judge is a BIG FAN of efficiency. Don't mess w/his system!

#WAOpioidTrial We're back from PM break, discussing when the state's case will be done and when defense will start theirs. Lots of moving parts.

McKesson's counsel begins their cross of Dr. Liebman here at 2:53pm; just about an hour left of the trial day.

Let's watch.

#WAOpioidTrial Staring with: He's not a medical doctor, he's never treated anyone with OUD, etc. etc. He's never created an abatement plan for opioids prior to the opioid litigation. That kind of stuff.

He's saying his abatement plan is different/separate from Alexanders'.

#WAOpioidTrial McK: The cost estimates you've presented today relied mostly on projections from Dr. Alexander, correct?"

Liebman: Correct.

McK: So if Alexander's numbers are wrong, then your cost estimates would be wrong as well, correct?

Liebman: Correct.

Hmm. 🤔

#WAOpioidTrial McK: You do not know what percentage of your projected costs would be attributable to people who have never taken RX opioids?

Liebman: I haven't done any type of analysis, no.

#WAOpioidTrial McK: In developing your costs & the numbers you presented today you've not evaluated any <opioids dispensed by pharmacies in WA> correct?

Dr. L: I'm developing a forward-looking solution; I'm not looking backwards at anything that happened in the past.

Hmm. 🤔

#WAOpioidTrial McK: You are not offering any opinions on the causes of the opioid crisis, correct?

Dr. L: That's correct.

McK: And you're not offering any opinions on whether the distributors <contributed to the crisis>?

Dr. L: Correct.

#WAOpioidTrial Also his cost projections are adjusted for future inflation - so the costs are in future dollar values. He did not present any current-value calculations.

#WAOpoidTrial McK is pointing out that Dr. L included the cost of counseling/therapy along w/ALL patients receiving MOUD (meds for OUD), after there has been much discussion about how counseling/therapy is NOT required for patients receiving MOUD. Challenging his math. Debating.

#WAOpioidTrial The disconnect may lie in Tricare terminology being different than civilian ...the person administering MOUD is 'counseling' patients (per Tricare) when they give meds, but not like - intense behavioral psychotherapy. Which is what I think is assumed by civilians.

#WAOpioidTrial McK is doing lots more math breaking down the costs of various MOUD meds and administration costs and such, mainly based on DOD/Tricare estimates.

Also Dr. L developed an abatement plan for the Purdue legislation in July 2019 for WA state. 🤔

#WAOpioidTrial Aha. That's the trick with these expert witnesses who testified in earlier trials: ask them the SAME question one anticipates they'd have the same answer. But often they do not. You'd better believe counsel has their previous transcript to show them the difference!

#WAOpioidTrial The line of questioning here appears to be: the overwhelming majority of the costs of the 'abatement plan' is people w/OUD receiving therapy. So if less are getting therapy, the costs would be MUCH less.

Here's what I'm wondering, though.

#WAOpioidTrial Where are all these qualified behavioral therapists supposed to come from?
In a perfect world, anyone w/OUD who wants therapy WOULD GET IT. But the thing is: we have a national shortage of therapists currently. Gods help you if you need an actual Psychiatrist!

#WAOpioidTrial Even if we somehow decide the distributors are responsible for ALL overdose crises/remediation in our state (and that's .. .ridiculous): throwing money at the lack of qualified therapists doesn't make them appear. We don't have them NOW. usafacts.org/articles/over-…

#WAOpioidTrial It was a critical public health issue BEFORE the pandemic. It's much, much worse now.

All kinds of people need mental health care. Including people with SUDs. This 'plan' cannot make providers magically appear. Wish that it could.

data.hrsa.gov/topics/health-…

#WAOpioidTrial AND ON THAT NOTE. Court is adjourned for the day and the week. Trial runs Mon-Thur weekly, 9am-4pm PT with breaks mid-AM & mid-PM, 90 mins for lunch 12-1:30pm.

BUT. NO TRIAL NEXT WEEK! Judge scheduled the week off ages ago. See you back - um, Tue 2/22/22?!😬Ciao!