CHARLESTON — Opioid distributors spent a full day of a trial in Charleston with a complex and thorough cross-examination of an epidemiologist in an attempt to disprove prescription opioids being a gateway to heroin abuse.
Katherine Keyes, an epidemiologist whose career at Columbia University has focused on opioid use disorder, testified last week the supply and oversupply of prescription pain pills is directly related to heroin abuse and the opioid crisis.
But McKesson attorney Timothy Hester pointed Monday to a report that said 99.8% of heroin users had a history of abusing more than just prescription opioids, the most common being tobacco and alcohol.
Hester spent hours cross-examining Keyes attempting to disprove her findings in an attempt to impeach her testimony as false, but the epidemiologist did not back down in her answers.
Drug distributors AmerisourceBergen, Cardinal Health and McKesson are currently the center of a trial in Charleston after they were accused by Cabell County and Huntington of fueling opioid abuse by shipping 127.9 million opiate dosage units into the county from 2006-14 before users were forced to turn to illicit drugs when the number of pills shipped dropped. The distributors believe it was the Drug Enforcement Administration, an uprising in doctor prescription combined with West Virginians’ history of poor health as the culprit.
Hester said association with something does not mean it was the cause. Not all smokers get lung cancer, for example.
Heroin was highly abused before the current opioids crisis began, he said. He pointed to a study that said in 2005, 8.7% of people surveyed entering opioid use treatment said heroin was their first used opioid. That number grew to 31% in 2015.
Keyes said that was not inconsistent with her findings.
Hester stated her reports are measured on the misuse of opioid prescriptions and the transition to prescriptions. Distributors have no control over how a person uses the pills once they leave the close system, defendants have held.
However Keyes said she had seen reports that said even people using opioids directly for medical purposes, opposed to non-medical purposes, still have a higher risk for contracting opioid use disorder, which leads to a shift in heroin.
Hester focused a large portion of time on the math she used to reach an estimated number of 8,200 Cabell Countians living with opioid use disorder, 5,800 of whom she attributed to prescription opioids. For about an hour, Hester walked her through her methods to reach the number, which he said was flawed.
Hester said Keyes only researched literature and does not know the proper amount of pills needed for Cabell County residents. Keyes responded that pre-opioid epidemic levels are the ones which should be considered as what was needed. To reach her opinion, Keyes reviewed hundreds of papers and studies, she said.
He then pointed to a paper she helped pen which blamed the crisis on a push to more heavily treat pain and the pharmaceutical industry’s advocacy for long-term use of opioids. The papers also said heroin played an important role when the price decreased dramatically.
“Pain needs and opioid prescribing are not synonymous,” she said.
Keyes pointed to a portion of an article which said increased distribution of opioids by the pharmaceutical industry also contributed to the crisis.
Keyes said in epidemiology you must look at the picture as a whole and not pick it apart, as the defendants have done.
Last week Keyes testified patients on opioids for more than 90 days have an increased chance of opioid addiction, but Hester pointed to an article Monday that said 65% of opioids were prescribed for less than three weeks and only 3% or 4% of the adult population has been prescribed longer term opioid therapy.
In attempting to show inaccuracies in her report, Hester pointed to an initial version, which directly attributed 104 of Cabell County’s 115 overdose deaths in 2018to prescription opioids. A second version dropped that number to 20 directly and 45 indirectly attributed to prescription opioids.
In explaining the change, Keyes said they had to change the methodology to take away fentanyl-related deaths, which had been counted as prescription opioid deaths.
Hester said Keyes cannot point to any diversion that occurred in the closed system between distributors and pharmacist. Keyes agreed the overwhelming majority of doctors prescribe in good faith.
Hester also said a number of the peer-reviewed articles on which Keyes relied upon to reach her findings were authored by professionals who are named as experts in opioid litigation or work for plaintiffs who accuse the defendants in other cases.
Keyes’ testimony is expected to conclude Tuesday.