CHARLESTON — A marketing specialist said opioid distributors accused of fueling the opioid crisis by shipping millions of opioid dosages to Huntington and Cabell County had some of the most sophisticated marketing she had ever seen.
Jakki Mohr, professor of marketing at the University of Montana, said the distributors engaged in marketing and worked as a channel between the pharmaceutical manufacturing companies and the customers.
She testified Friday that distributors marketed to manufacturing companies — like Purdue Pharma — prescribers and pharmacies to increase pharmaceutical sales. At the same time, they ran public relations campaigns with a distribution trade association to create a better appearance with media and the public.
Katherine Keyes, an epidemiologist focusing on opioid use disorder at Columbia University, later testified that the supply and oversupply of prescription pain pills is directly related to heroin abuse and the opioid crisis.
The testimony took place Friday at the Robert C. Byrd U.S. Courthouse in Charleston during a trial in which Huntington and Cabell County accuse the “Big Three” drug wholesalers — AmerisourceBergen, Cardinal Health and McKesson — of fueling the opioid crisis by sending excessive shipments of opioids into the area for eight years, before a reduction in the number of pills shipped made users turn to illicit drugs.
The defendants point to the Drug Enforcement Administration, doctors and West Virginians’ poor health as the culprits.
At the questioning of Huntington attorney David Ackerman, Mohr said the defendants offered a paid service to pharmaceutical manufacturers to market on their behalf, referencing several brochures and presentations produced by the companies.
She said ABDC worked with Xcenda and Lash Group. Xcenda is a specific unit of ABDC that provides marketing services to the manufacturers. Xcenda was acquired by AmerisourceBergen Drug Corp. in 2007, around the time the amount of prescription pills being shipped into the area dramatically increased. Lash Group is a marketing consultant.
Mohr said while separate companies, the groups worked together under the umbrella of AmerisourceBergen Drug Corp. to turn a profit.
She said before “pay-per-click” advertisements came on websites such as Google around the turn of the century, Bergen Brunswig — now ABDC — had its own system, known as “the glimmer button.”
The company would offer to advertise a manufacturer’s product for a price and when a pharmacist ordered a certain product, they could click a button in the system and an advertisement encouraging the purchase of OxyContin would pop up, she said.
Mohr referenced an email in which a Purdue Pharma employee encouraged the manufacturer to utilize the offers from the distributors to market their product for better sales.
In another example, she said if a manufacturer could subscribe to a “first-script” service for $15,000, the distributor would notify pharmacists of a promotion from their business.
McKesson also had an “RX Focus Launch” program that automatically would ship newly launched drugs to pharmacists who subscripted.
The companies also created a patient adherence program to make sure people utilized products once they were purchased. They also used thought leadership marketing by hosting trade shows in which pharmacists could learn about new drugs, and also offered continuing education classes, which are required to retain licenses.
Mohr said the distributors hired the speakers at the events to keep the payments off manufacturers’ books, which she believes meant the distributors were able to control what the speakers said.
Mohr said ABDC also hired “key opinion leaders,” someone who could engage with a more personal audience, to promote the product.
The distributors also engaged in public relations campaigns via their trade organization, the Healthcare Distribution Alliance, which represents distributors as a whole.
The defendants asked for Mohr’s testimony to be thrown out, stating she presented stated marketing occurred, but failed to connect it to sales related to Huntington and Cabell County. She has no experience with prescribing, sales or other areas, ABDC attorney Shannon McClure said.
“The existence of marketing provides nothing,” she said.
After Mohr left the witness stand, the plaintiffs turned back to epidemiology through Keyes, who researched peer-reviewed articles and used her own education and calculations to determine heroin abuse and the opioid crisis were directly caused by the oversupply of prescription pills into the county.
Using a mathematical equation based on data she interpreted, Keyes said she found about 8.9% of Cabell County residents — about 8,200 people — live with opioid use disorder.
A paper penned by Theodore Cicero in 2017 asked people entering substance abuse treatment about the specific opioid they first regularly used to get high, Keyes said.
The study showed the majority of people suffering from opioid use disorder throughout the 1960s-1980s started their abuse with heroin rather than prescription opioids. In the 1990s, user numbers were even before prescription opioids became the first-used drug for people who suffered from substance use disorder from 2000-17.
Another study showed the higher the dosage of an opioid and longer duration a person was prescribed opioids, the higher chance the user would have of being diagnosed with opioid use disorder.
Patients who were taking opioids at high doses for 90 days were 122 times more likely to become addicted than others who used lower doses for lesser time, she said. A person prescribed a medium dosage was 26 times more likely, and low dosages were 15 times more likely.
As an example of how severe that was, she referred to a study that connected smoking to lung cancer, which showed smokers were 13 times more likely to get lung cancer than others. Compared to that, the connection between opioid use and addiction is “extraordinarily high,” she said.
Keyes said several studies show economic conditions play a small role — less than 10% — in the opioid-related harm seen in the United States over the past 15 years. The crisis is majorly based on the availability and price of prescription opioids, she testified.
The defendants have held through trial that Huntington’s economic decline is a major factor in what led to the crisis.
Keyes will continue her testimony Monday, answering questions from the defense.