CHARLESTON -- While opioid distributors have argued there is no proof of connection between prescription painkiller use and illicit drug use, an expert in the neurobiology of addiction said, during the second day of a landmark federal trial against those distributors, that people who take prescription painkillers and illicit opioids see the same changes in their brain chemistry.
Dr. Corey Waller, an Michigan doctor with expertise in pain and substance use disorder, testified May 4 at the federal courthouse in Charleston. Lawyers for the City of Huntington and Cabell County, which sued the “Big Three” drug distributors, McKesson, AmerisourceBergen, and Cardinal Health in 2017 over their role in the drug crisis, called him to testify.
Plaintiffs argue defendants are at least partly responsible for the opioid crisis after more than 80 million doses of the drugs were sent to the area in an eight-year period. They argue that the ongoing fentanyl crisis, and the rush of heroin into the region after painkillers became less available, are tied to overshipments of prescription painkillers, including oxycodone and hydrocodone, into the region.
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Senior U.S. District Judge David A. Faber is presiding over the trial, which is expected to last several weeks.
Paul Farrell Jr., an attorney for Cabell County, asked Waller about the molecular structure of heroin, oxycodone, and hydrocodone.
“The core molecule is absolutely identical,” Waller said.
Waller, who is also the editor of The ASAM (American Society of Addiction Medicine) Criteria, said even prescription drugs alter the brain’s function, namely the “dopamine pathway.”
That’s because that reaction is based on the potency of the drug, not the specific type of drug, like whether it’s heroin or a prescription, he said.
Farrell asked if oxycodone and hydrocodone use is a “gateway” to heroin use.
Waller said he doesn’t use that term.
“For some people, it's no different for them," he said. "Because when they take oxycodone or hydrocodone, for them, if they have that same change in the brain chemistry, they might as well have taken the other.
"It's an opioid that bonds in the brain disproportionately releasing this dopamine and causing this same behavioral phenomenon with this need to search for dopamine.”
Farrell also asked about fentanyl, which has driven overdose deaths in West Virginia in recent years.
“Fentanyl happens to do this in a way that turns the receptor up about as high as you can get,” Waller said.
Jennifer Wicht, representing Cardinal Health, asked a series of questions asking him to confirm opioids are FDA-approved, prescribed by trained, licensed medical professionals and sold by licensed pharmacies, which he did.
“As long as it’s to a patient who has a valid prescription right?” she said
“Sometimes,” he responded.
"Is it your opinion that oxycodone can be dispensed to a patient who does not have a prescription?” she asked.
“It wasn’t about the prescription, it was about the term legitimate,” he said.
Also under questioning from the defense, Waller agreed that factors like genetics, environment, and life experiences also influence susceptibility to addiction.
Dr. Rahul Gupta, the former West Virginia state health officer and commissioner of the state's Bureau of Public Health, is expected to testify Wednesday.
Gupta, who worked in West Virginia from 2009 to 2018 before leaving for the March of Dimes, is expected to testify about the transition from prescription painkillers to illegal drugs like heroin and illicit fentanyl, among other testimony.
Defendants had filed a motion to limit his testimony.
Steve Ruby, a lawyer for the defendants, brought up Gupta's expected testimony. He said defendants weren't given enough time to review four studies Gupta relied on. He said they were given author names but not titles, dates and citations.
“You’re not suggesting, Mr. Ruby, that everything that he relied on as a basis of his opinion has to be disclosed, are you?” the judge asked.
Ruby said the defense is opposed to Gupta testimony relying on outside studies.
“You can object at the time,” Faber said. “I'll be better informed about what the issue is at that time, but it seems to me that this is not something that should come up… but i'll give you a shot at keeping it out as he testifies, Mr. Ruby, and that's the best I can do .”
The judge was engaged during the trial, asking his own questions several times.
Timothy Hester, representing McKesson, asked Waller to review, for the first time, several written statements, including decades-old West Virginia Board of Medicine newsletters, excerpts from a book and journal articles. He pointed to statements about the value of opioids and its appropriate use and asked Waller whether he was familiar with them.
Waller said several times that he is an expert in treating pain, not pain treatment history.
Wicht asked about several pieces of plaintiffs’ proposed $2.6 billion abatement plan, which includes funding for naloxone and medication-assisted treatment.
She asked whether he was aware of distributors ever refusing to make those supplies available, and he responded that he hadn’t.
During a tense moment at the end of the day, she asked about the part of the plan that would pay for clean syringes for harm reduction programs.
“I would say the distributors could fix that problem all by themselves if they wanted to,” Waller said. “In your warehouses sits millions of clean syringes.”
She asked if he was aware of distributors refusing to provide syringes.
“I was speaking as an abatement process to help a community, not as a ROI,” he said.
She asked him to repeat his last word.
“Return on investment,” he responded. “Meaning the syringes sit in warehouses."
“Until customers order them, right?” she asked.
“Or until it’s felt to be in the greater good to actually give away some of those so that we can decrease harm," he said.
She asked if he was suggesting a voluntary contribution by distributors.
“Wouldn’t that have been great before we saw HIV explode in Indiana or Hepatitis C decimate entire portions of the country?
Both of those diseases are associated with needle-sharing. In March, a CDC representative told Kanawha County officials that the area has the "most concerning" HIV outbreak in the United States.
She told him distributors had already undertaken such an initiative.
The trial resumes May 5.
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)