CHARLESTON – At the federal trial against three major opioid distributors, a child welfare expert showed the impact of Opioid Use Disorder on children and the rising need – and lack – of proper resources.
Cabell County and the City of Huntington sued the three largest pharmaceutical distribution companies – AmerisourceBergen, Cardinal Health and McKesson Corp. – in 2017 claiming the companies were largely responsible for the opioid crisis after the companies shipped more than 81 million hydrocodone and oxycodone pills to the county of just 100,000 residents between 2006 and 2014.
On June 16, Linda Singer, representing the City of Huntington, called Nancy Young, co-founder and executive director of Children and Family Futures, to testify as an expert witness.
Young said her company works with programs across the country, including some in West Virginia and Cabell County, on understanding what is working and what challenges the jurisdictions are facing in terms of substance use disorder and the impact of opioids on children and families.
Young testified she was asked to “look at the evidence base of what works with families of opioid use disorders and provide evidence of programs and cost.
Around 2010, Young said the company was tasked with getting a handle on what was going on with opioids and the impact on the child welfare system.
Young said after years of work to reduce the number of children in protective custody, the trend line completely revered in 2012, sometimes overwhelming Child Protective Services (CPS). With the increase of OUD and overdose deaths, fewer children were able to get out of the foster care system.
This has also led to an ongoing increase in infants placed in protective custody. Young said about 50k infants are placed in protective custody across the nation each year. 20% of those are OUD related. In West Virginia, 80% of those are OUD related.
More children were being placed with grandparents or in other kinship placements, childcare social workers took on the mental load, the number of children needing care outnumbered foster homes and some children went into protective care indefinitely.
Young said CPS had not dealt with orphans since the Industrial Revolution, which ended in 1913. The increase of children without living parents was due to the increase of overdose deaths.
Children aged 5 and up are considered adolescents, according to Young.
Young said children face several challenges from exposure to substance use disorders including the mental and emotional toll, a greater chance of addiction and getting past the thought of “why they weren’t enough for their parents to quit using and not place their worth on their parents.”
Young said it is important to not treat just the individual, but to treat the family. She said there needs to be intergenerational programs that focus on needs of all family members and how they function together.
Young broke down the those requiring intervention into five categories: pregnant women with OUD, children affected by prenatal OUD, infants born with Neonatal Opioid Withdrawal Syndrome (NOWS) or Neonatal Abstinence Syndrome (NAS), children affected by parental opioid and other substance use involved with child welfare services and adolescents and young adults.
She then looked for interventions that work, proportions children needed, frequency and duration of services needed and the estimated cost from literature. Young said she did her report mostly during COVID-19 quarantine, so she relied on her staff in the area.
“I actually didn’t think it was necessary for what I was asked to do,” Young said. “I was asked to look at the literature and what does the literature say on evidence-based programs.”
Young said there is an issue with the system that makes it more difficult to separate opioid use from other substances.
“We really can’t separate out opioids from other substance,” Young said. “The federal government doesn’t collect data that way and it’s not data states are required to report.”
Young said opioids are unlike anything worked with before.
“DHHR reports 80 percent [of] children removed [are] affected by substance abuse,” Young said. “Social workers report overwhelmingly opioids.”
Young said the shorter time between intervention treatment the more likely that reunification is possible. This is why it’s important that when “a parent reaches out for help, the help is there.”
“The capacity is not there and even though the grant writers in Cabell and Huntington are extremely good, and they have had lots of grants come in, all of those grants- it’s a lot of administration,” Young said. “it’s a lot of time taken to secure grants, administer the grants, report the grants. They’re really meant to be innovations and for communities to be able to sustain. review what works and how to sustain.”
Young said children in the welfare system due to opioid use also face several traumas including separation, kids experience overdoses, watching parents be taken away in handcuffs.
“Trauma for children that they have experienced, all across the country,” Young said. “In California, I knew what was going on in West Virginia because of the awareness children were going through whose parents were addicted [to opioids].
Young said services are needed to help increase “their ability to be reunited and to address their trauma.”
A slide was presented titled, “Estimated WV out-of-home population” that showed between 2006 and 2016 children removed due to substance use went from 970 to 2,171. Between 2011 and 2016 approximately 80 percent of cases in which a petition for court custody of a child was filed involved parental substance abuse.
Another slide was presented showing in 2016 overdose deaths and foster care injuries in West Virginia were above the national median. All but six or seven counties were included.
Young said children with exposure need intervention. She said their brain is still under development and “not fully developed for decision making, emotion regulation and impulse control.”
“They need specialized programming that helps them solve some of their own challenges,” Young said. “Children of parents with opioid use disorder are at greater risk of developing their own substance use disorder and more likely to engage in riskier behaviors around substances.”
Young testified that pregnant women with OUD have usually went through their own trauma. She said they have seen success in programs for women seeking treatment during pregnancy and those who were allowed to stay with infants to bond.
Young said the most critical time for proper intervention is infancy, toddlerhood and preschool ages.
West Virginia Department of Human Resources reported NAS incident rates of 50.6 per 1000 births.
“In my view, we all have responsibility to these kids that they have the life chances we all have,” Young said.
Attorney Gretchen Callas, representing AmerisourceBergen, led the cross-examination.
Callas argued that alcohol is the only substance tracked in West Virginia, which Young argued is not true. She said all substances are tracked, but it was hard to determine specifics such as opioids, so other data is relied on.
Callas asked a pattern of questions on Young’s knowledge of various programs, the funding and several other aspects that Young said was beyond the scope of what she was asked to do.
Callas connected several programming to federal funding and ways to seek assistance including special education.
“Issue with prenatal exposure, they are invisible disabilities,” Young said. “[It is] fierce competition [to get in].
When Callas asked about the cost and funding of programs within Cabell County being federally funded, Young made clear that it was not free money.
“I think it’s really important to realize the federal finding is not free,” Young said. “That is paid for by the taxpayers of West Virginia and the United States.”
Callas referenced a grant that Cabell County has not utilized yet, something Young said is common due to restrictions and something Congress has addressed.
“We’ve never had these kinds of funds put in substance abuse treatment in my career,” Young said. “Congress is recognizing that there needs to be additional funds. There’s always a lag in federal dollars.”
In terms of Medicaid coverage for intervention treatments, Young said she was not aware of West Virginia’s benefits package, but it is limited.
“Medicaid has a limited benefit package. It is typically the healthcare cost that’s covered by Medicaid because it covers medical care. It doesn’t cover social support [or] things women need,” Young said.
Attorney Laura Wu, representing McKesson, led a short cross-examination focused on the five populations and the specifics of them to Cabell County and Huntington.
“Wide number come to Cabell for treatment. Expenses of women being absorbed by Huntington Hospital where they are being treated, does not matter if [they] do not live in Cabell,” Young said. “I just know if the service is being delivered in Cabell County, you would be having those expenses in Cabell County, no matter where you lived.”
Young said as an example Cabell County has no way to ask Kentucky to give them back, they money used for their residents.
Robert Fitzsimmons was presented by Paul Farrell Jr. to call Kevin Yingling to the stand.
Yingling is a practicing physician, former pharmacist, chairman of the board for Cabell County Health Department and has held multiple positions within Marshall Health.
Yingling said the health department collects all important data in the county to help allocate resources to needs and determine what needs attention.
Wu led the cross-examination with a pattern of questions pertaining to the process of distribution centers purchasing pharmaceuticals from manufacturers to ship to licensed and registered pharmacies and hospitals, the responsibility of pharmacies and Yingling’s knowledge of certain drugs uses.
Wu presented a slide deck from a presentation Yingling had used.
“End of the 1990s were alerted to address pain more specifically. Pain is a very subjective thing,” Yingling said.
Wu questioned Yingling’s increase in prescriptions written, as well as fellow physicians in the area.
“Attempt to move from subjective object of pain to an objective object of pain,” Yingling said. “To the degree it was moving from a subjective assessment to an objective assessment and quantifying it. There was a responsibility of physicians to become more attentive.”
In 1995, the American Pain Society designated pain as the fifth vital sign.
Yingling clarified the presentation was from an alumni event he was asked to speak, where he chose an odyssey theme of the medical school with information that was public and not necessarily what he believed in.
Wu ended her questioning with a pattern of questions about Marshall University being a part of or funded by the City of Huntington, with no other related questions.
Callas led a quick cross-examination with questionings in reference to Cabell County hospitals and medical facilities in the area.
Attorney Steve Ruby, representing Cardinal Health, led a cross- examination on opioid regulations regarding the needs of patients and the role of the Coalition on Chronic Pain Management.
Ruby clarified through questioning of a Coalition meeting agenda, the legal limits on opioid prescribing in 2016 under SB 273, the first regulations made in West Virginia.
The Coalition meeting also had recommendation notes that stated, “SB 273 has inadvertently and inappropriately interfered with the patient-practitioner relationship.”
During the redirect, Fitzsimmons clarified with Yingling that heroin is often lumped in as an opioid but is an opiate.
Yingling’s testimony finished with his opinion that Huntington has shown the town can overcome with next to nothing.
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)