SEATTLE (Legal Newsline) - An addiction expert witness called by the State of Washington said that a massive over supply of opioid pills in the early 2000s is linked with heroin use and caused an overdose epidemic in the state.
“Opioids are cheap, high dose, ubiquitous, pervasive,” Daniel Ciccarone said. “They have been perceived as safe, regulated doses. It’s a slippery slope. When the pills became scarcer, heroin became a substitute.”
Ciccarone, a family and addiction professor-researcher at the University of California San Francisco, during testimony on Monday and Tuesday, portrayed the epidemic as a linked chain, an overabundance of opioid pills leading to heroin use addiction followed in recent years by a more potent synthetic product…fentanyl.
Ciccarone called the phenomenon unprecedented and a “triple wave.”
Defense attorneys for three of the country’s biggest opioid distributors maintained that it was societal misuse of illegal drugs that caused the epidemic.
Prescription drug distributors McKesson, Cardinal Health and AmerisourceBergen Corp. are accused of irresponsibly over-promoting and distributing opioid drugs to pharmacies and doctor’s offices that led to multiple overdose deaths in the state. The Washington State Department of Health estimated 1,200 in 2020.
The trial now in its second month is being streamed live by Courtroom View Network.
The lawsuit launched by Washington State Attorney General Bob Ferguson is asking for $32 billion in damages to enact anti-drug programs, but a state victory could result in a much higher award when surrendered profits and penalties are added in.
The distributors take the pills from the manufacturers and supply them to hospitals, doctor’s offices and pharmacies. The most commonly shipped opioid drugs include OxyContin, Hydrocodone, methadone and fentanyl.
Ciccarone portrayed the drug dependency as a step-by-step escalation, opioid pills to heroin use to fentanyl.
“People have said ‘I never thought I would crush the Oxycontin tablet and snort it. I never thought I would get into heroin,'” he said.
He added that pill use led to a body-tolerance for the drug and a craving for a stronger drug from a rewiring of the brain.
“Most started their problem with opioid pills,” Ciccarone said. “There was a massive oversupply of pills. Heroin was cheap and available. Some moved on to the more potent fentanyl.”
Ciccarone said a new generation of heroin and fentanyl users has been created, as many as 1.5 million, with profound impacts including growth in viral infections from the sharing of syringes such as hepatitis B and HIV, more hospitalizations and mental health cases. Fentanyl is 40 times more potent than heroin. A Mexican drug cartel couldn’t meet the demand for heroin so a synthetic fentanyl was created, Ciccarone added.
He called opioid use a “gateway” to heroin. Teenagers who started on opioids graduated to heroin use by their 20s. Heroin was cheaper and a more reliable drug to acquire.
“Pills and heroin are similar, they effect the brain in the same way,” Ciccarone said.
Linda Singer, an attorney for the state, asked if the concept was unproven.
“No it is well established,” Ciccarone answered. “Addiction is a brain disease. The symptoms are craving, compulsion, and personality disease disorder. We’ve had 1.5 million new users in a rapid period of time. Without a massive oversupply of opioid pills the epidemic would not have happened.”
Defense attorney Timothy Hester, representing McKesson, sought to establish the difference between illegal drug use and that of legal medically prescribed opioids.
“There is a difference between medical use and non-medical mis-use,” he said.
“Correct,” Ciccarone said.
“Mis-use is use without a prescription, it could be a pill given by a friend or a family member.”
“Correct.”
“Mis-use could include crushing or snorting.”
“Correct.”
“Heroin users who said they were hooked on opioids could have gotten them from family and friends or on the street.”
“Correct,” Ciccarone said.
“The risk of transmission from opioids to heroin from medical use is less (than illegal use).”
Ciccarone agreed.
Hester displayed a document that said, “Each era has its problematic drug defined by a cultural desire, but is independent of a specific type of drug.”
“This is a long-term process not related to any specific drug,” Hester said.
Hester said there was a conception in the 1990s (among doctors) that chronic pain including that for cancer treatment was under-treated, and led to an increase in the proscribing of pain pills.
“Yes,” Ciccarone said.
Hester said there were many contributing factors to the opioid crisis including doctors misunderstanding the prescribing of the drugs, an underestimation of the risks.
“That’s my understanding,” Ciccarone said.
Another chart displayed by Hester showed a majority of heroin users saying they had used prescription opioids “non-medically” before initiating heroin use. Approximately 94% in a survey said they had used other psycho-active substances prior to heroin, instead of using opioids first.
Hester said prices for heroin dropped over the last decade from $1,368 a gram in 1993 to $680 in 2008.
“Is this correct?” Hester said.
“Yes,” Ciccarone said.
“From 2010 to 2014 it (price) halved?”
“Yes.”