White pills spilling out of a prescription bottle.

Doctor testifies to seriousness of opioid prescribing as defense takes reins of trial

This article was originally published by the Huntington Herald-Dispatch.

HUNTINGTON — Distributors accused by Cabell County and Huntington of fueling the opioid crisis presented their first witness at a months-long trial Friday, a pain doctor whose testimony in effect strengthened the plaintiffs’ theory of there being a gateway between prescription opiates and heroin use.

The defense’s first witness, Dr. Christopher Gilligan, chief of the Division of Pain Medicine at Brigham and Women’s Hospital, testified to the gravity doctors have to use when determining whether opioids should be prescribed.

He said they had to weigh the risks and benefits of opioid prescribing, while trying to satisfy the ever-changing policies of their regulators and medical board who set prescribing standards. Asked by McKesson attorney Paul Schmidt if the drug distributors had a say in a patient’s treatment or physicians’ prescribing methods, he said no.

However, Cabell attorney Paul T. Farrell Jr. turned his testimony on its head by referring to papers and presentations presented by the doctor, which said prescription opioid use was a large factor in a shift to illicit drug use among people with opioid use disorder.

The trial stems from the municipalities’ accusations against AmerisourceBergen Corp., Cardinal Health and McKesson Co., which they accuse of fueling the opioid crisis by shipping 127.9 million dosage units of opioids to the community over eight years before a reduction of shipments made people with substance use disorder turn to illicit drugs.

The distribution companies blame the Drug Enforcement Administration, doctors’ prescribing habits and West Virginians’ history of poor health.

Gilligan said sometimes his patients try all other treatment options to no avail and have no choice but to look to treatment with opioids and other medications to help. Gilligan said access to pain medication was a human right under international law.

“Not only do they suffer from the pain, but they have their life being taken away from them by the pain,” he said.

He said doctors weigh the risks and benefits to determine how likely a patient is to develop an opioid use disorder (OUD). To determine the risk of OUD, doctors look at the patient’s mental and family history. They also look at how well the other treatment options work.

Today, labels are clear and warn of addiction, abuse, neonatal opioid withdrawal syndrome and misuse. They also alert doctors that they should assess a patient’s risk of OUD. Gilligan said he takes these warnings very seriously when he is making a decision on whether or not to prescribe opioids.

He said it’s rare among his patients that people he has prescribed opioids move to heroin, and referenced “Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States,” published in 2013.

The study, which used data from 2002 through 2011, found that the recent heroin initiation rate was 19 times higher among those who reported prior nonmedical pain reliever use than among those who did not (0.39% vs. 0.02%).

Within the study, it showed in the 12-49 age group, 1.1% of people using heroin had no prior history of abusing pain medicine or illicit drugs. Schmidt said this shows that 98.9% of people using prescription opioids do not acquire opioid use disorder.

While the overall study shows prescription opiates have a role in the turn to illicit opioid abuse, Schmidt said the risk is low for those who use the drugs as prescribed.

At the questioning of Farrell, Gilligan said while misuse and abuse of prescription opioids contributed to the current crisis, he thinks other factors could have contributed to it as well. Nonetheless, he agreed there is evidence pills were being diverted into the illicit market, but he said that came from sharing between family and friends, not by doctors.

Huntington attorney David Ackerman said studies show in 2009, half of patients who filled an opioid prescription filled a second within 30 days. Another study showed 3% of chronic noncancer pain patients regularly taking opioids developed opioid abuse, while 12% developed aberrant drug-related behavior.

Gilligan agreed with Farrell that a large number of medicines being sent to an area would lead to misuse and diversion, which would lead to people using heroin, seemingly affirming the gateway theory between prescription pills and heroin.

“I think there is a direct relationship that includes the misuse (…) along with many other factors that does relate to the use of heroin,” he said.

Farrell referred to a study that said the vast majority of prescription opioid users do not move to heroin, but that the reverse happens. Farrell said it shows that the number of people who used heroin first was 1%, and 80% had used prescription pills, a statement with which Gilligan agreed.

Looking at a presentation published on YouTube in March, Farrell said Gilligan said the same. The reason for the shift was that heroin became cheaper and more accessible, he said.

Another article said, “Nearly 1 in 3 adolescents in recent studies who reported nonmedical prescription opioid misuse transitioned to any heroin use,” Farrell said.

Farrell also pointed to one of Gilligan’s old presentations in which he said as opioid prescribing and sales increased, so did overdose death and treatment admissions. Doctors are bound legally to their patients’ actions, Gilligan said, and are heavily scrutinized on their opioid prescribing and face consequences if they make the wrong choice.

That has not always been the case, however, he said. Since the 1980s, the standard of care for opioids prescribing has changed several times, bouncing from being less to more restrictive over time.

Around 2000, the Joint Commission, West Virginia Board of Medicine and other groups started shifting standards and asked doctors to treat pain as the fifth vital sign. Gilligan said prescribers took that as a sign they were underprescribing opioids and needed to take pain complaints more seriously.

Around the time prescribing peaked in 2010, West Virginia doctors had been told they should not fear possible investigations if they were treating legitimate pain.

Ackerman pointed to reports that said the effectiveness of opioids as pain relievers, especially over the long term, is unclear and oftentimes does not treat pain — it just masks it.

Gilligan said he felt the vast majority of prescriptions were well intentioned. He said today, opioids are still utilized in the medical community, but doctors are much more conservative with their prescribing.