CHARLESTON – Testifying in the bellwether opioid trial, a expert witness on pharmaceutical-related abatement programs said he does not believe Cabell County has sufficient treatment programs to fight the opioid epidemic.
The City of Huntington and Cabell County sued three of the nation’s largest pharmaceutical distribution companies – AmerisourceBergen, Cardinal Health and McKesson Corp. – in 2017 claiming the companies are largely responsible for fueling the current opioid epidemic that led the area to lead the nation in prescription opioid related deaths and at one-time being named the “epicenter of the opioid crisis.
The federal bench trial, part of a larger national Multi-District Litigation case, resumed June 28 after a weeklong break.
Faber
Attorney Linda Singer, representing the City of Huntington, called G. Caleb Alexander to the stand as an expert in pharmacoepidemiology, abatement and division.
Alexander testified he was asked to identify evidenced-based services for the Cabell County/Huntington area and aid in the calculation of an overall unit cost.
Alexander said he used several information including data from the CDC, WV Department of Human and Health Resources, US Census, Substance Abuse and Mental Health Services Association, peer reviewed reports, advice from colleagues and spoke with several on-the-ground experts.
“There is abundant evidence of an ongoing epidemic, an opioid epidemic,” Alexander said. “There is overwhelming evidence of the nature of harms.”
Alexander said the number of fatal overdose rates and overdose emergency room visits for a community [Cabell County] of 100,000 are off the charts, putting a burden on schools, child welfare and more.
In 2018, 137 individuals died of opioid overdoses. There are 7,882 residents with Opioid Use Disorder and in 2016, 17.6 percent of umbilical cords tested positive for opioids.
“It’s hard to find communities in the United States with this many individuals with Opioid Use Disorder,” Alexander said. “The evidence just goes on and on.”
While what is considered an opioid has been debated during the trial, Alexander said they come together as a whole with the same effects. He also said he would not cite the epidemic specific to one drug.
“Prescription opioids, heroin and fentanyl are two sides of the same coin,” Alexander said. “I would characterize it as an opioid epidemic, not a specific drug.”
Alexander said the abatement program is a multi-faceted plan and the treatment is just one piece. He said it involves many other support systems which include prevention, treatment, recovery and special populations.
Alexander testified that there was not a lot of conflict in the health community on the effectiveness of properly implemented abatement programs.
I think it can [referencing abatement program helping the county] I think there is clear evidence that it can,” Alexander said. “You can’t do this on a month-to-month basis, not knowing the funding in the beginning of the year.”
Alexander said it is important to have the programs ready for the long-haul and he does not believe Cabell County’s programs are ready.
“The current programs, while important and the local community deserve credit for them, I think they are insufficient,” Alexander said. “There has to be a mission plan. I think the community has what it takes.”
Alexander said there needs to be more education for healthcare professionals, something with a targeted message to the subset of high prescribers on why that needs to change.
A paper Alexander wrote was presented and a line read, “opioids are not the first line or routine therapy for chronic pain.” He said this has been vastly applied to the community without highlighting the fact that opioid have potential for real and evident harmful results.
Alexander noted that evidence for prevention programs shows for every $1 invested in abatement, $5.30 would be saved in reduced crime and criminal justice costs.
“Treatment works,” Alexander said. He said with the safe and effective medicines to treat opioid addiction along with the other programs, the intergenerational cycle can be broken.
“Treatment isn’t just the right thing to do, it also makes positive economic sense,” Alexander said. “We can disrupt the intergenerational transmission cycle of addiction. Families that have addiction, addiction is not just in one generation of the family. Having a household member [with addiction] is a significant risk factor for a child to have [substance use disorder].”
Alexander said he recommends the various programs because relapse is an important feature of OUD and needs to be addressed.
“Relapse is not a unique feature of OUD alone,” Alexander said.
Alexander shared data that showed the death rate was less than 1 in 100 person-years while in treatment; the death rate was 5 per 100 person-years to those who have never received treatment and fewer than 2 per 100 person-years for those who have received treatment.
“It’s important to meet people where they’re at and support treatment,” Alexander said.
Alexander testified that FDA approved treatments for opioid treatment can decrease risks of mortality by as much as 50 percent in some studies and that the medications are generally well tolerated. He said these medications address the “almost overpowering” physiological cravings driven by the change in brain chemistry from OUD.
With barriers like housing, economic security, cost of treatment, stigma and at per-year capacity; Alexander said he does not believe Cabell County has sufficient treatment programs and there is room to expand.
In 2017, 54 of every 1,000 children in West Virginia were affected by the opioid epidemic. Nationally that number was 28 per 1,000 children. Over half of West Virginian children are living in a home with a parent who has OUD. Nearly 1 in 5 have lost a parent to death or jail. Nearly 1 in 5 have been removed from their homes. Of the roughly 22,000 children affected, 1,500 will develop OUD or accidently ingest opioids as a child.
Alexander believes with the proper abatement program in place, the number of people with substance use disorder could decrease by 50 percent within 15 years.
Many calculated costs for a proper abatement program were presented to be admitted. All three defendants objected on the grounds of hearsay and that a part of an expert report should not be admitted. After a break for review, U.S. District Judge David Faber ruled that he would provisionally admit it for the time being.
Later in the testimony, Faber expressed his irritation.
“It irks me, I could not admit this but could consider it a demonstrative,” Faber.
“We would agree it’s a demonstrative to aid in his testimony, but it’s not evidence,” said Timothy Hester, representing Cardinal Health.
Alexander said under the proposed plan, 3,253 people would be treated within the first year. The treatment would ramp up over the course of 15 years and could be slowed with the decrease of population with OUD.
Alexander suggested the treatment infrastructure include four levels of treatment with daily costs: outpatient – $63.77, intensive outpatient – $69.01, residential – $78.15 and inpatient – $78.95.
These numbers were all forward looking and did not include those already getting services.
“We’re talking about hundreds or thousands of lives to be saved and many, many more if you think of the ripple effect- 50% reduction would represent an enormous change,” Alexander said.
Alexander said the plan would build on community efforts by increasing breadth of services, increasing depth of services and increase the duration of services.
“My professional opinion, with these investments and these programs and services, the community will be in a much better place and better to handle ongoing harms at a much better level than they are now,” Alexander said. “[With the] magnitude of the epidemic, more is needed.”
While commending the community efforts, Alexander said there is more that can be done.
“They [community] have done a remarkable job with not very much,” Alexander said. “These programs are used all around the country, all the time. This is not something beyond the capability of this community. It will take hard work and it will take resources.”
When the defendants asked Alexander a series of questions about his abatement plan being used for things outside of prescription opioids, he made it clear of his opinion.
“I think there is one epidemic, not two,” Alexander said. “An opioid epidemic, not a prescription opioid epidemic and heroin/fentanyl epidemic.”
The remainder of the cross-examination revolved around disputing the numbers for needed and predicted treatment plans calculated by Alexander.
Hester tried to find flaws in the math done by Alexander by calculating different assumptions, something Alexander had a hard time following.
Hester also questioned Alexander’s knowledge of law firms from Cabell County and Huntington funding papers used as resources. Alexander did not recall his knowledge.
Huntington is represented by Anne Kearse, Joseph Rice, Linda Singer and David Ackerman of Motley Rice and Rusty Webb of Webb Law Centre. Cabell County is represented by Paul Farrell Jr. of Farrell Law, Anthony Majestro of Powell & Majestro and Michael Woelfel of Woelfel & Woelfel.
AmerisourceBergen is represented by Gretchen Callas of Jackson Kelly and Robert Nicholas and Shannon McClure of Reed Smith. Cardinal Health is represented by Enu Mainigi, F. Lane Heard III and Ashley Hardin of Williams & Connolly. McKesson is represented by Mark Lynch, Christian Pistilli, Laura Wu and Megan Crowley of Covington & Burling.
U.S. District Court for the Southern District of West Virginia case numbers 3:17-cv-01362 (Huntington) and 3:17-cv-01665 (Cabell)
