(CN) — San Francisco's opioid trial picked up Monday after a one-week hiatus with the expert testimony of Dr. Anna Lembke, who said Walgreens and three other defendants in the civil suit helped spread misinformation that led to the opioid crisis that took nearly half a million lives.
Attorneys for the defendants have argued that Purdue Pharma, which invented, manufactured and marketed Oxycontin, was principally responsible for the opioid epidemic.
Lembke, a Stanford University professor who teaches, conducts research and treats patients and the author of "Drug Dealer, MD" and "Dopamine Nation," argued that the defendants were also responsible.
"The defendants in this case used misinformation to target doctors," Lembke testified. "Walgreens actively collaborated with Purdue to educate their pharmacists on the use of treating pain with opioids."
She added: "Walgreens strategized with Purdue about how to get these messages out there."
The trial marks another instance of a governmental entity accusing drugmakers and sellers of creating a "public nuisance," an attempt to collect damages over an addiction epidemic that persists to this day. This past November, an Orange County Superior Court judge ruled in favor of four pharmaceuticals, including Teva, in a suit brought by four cities and counties. That same month, the Oklahoma Supreme Court overturned a $465 million ruling against Johnson & Johnson.
A jury trial in Florida ended midtrial, when Walgreens agreed to settle claims brought by the Sunshine State and its cities and counties for $683 million. Florida has received more than $3 billion from opioid litigation settlements, some from Teva and Allergan.
San Francisco's lawsuit began in 2018 with a panoply of defendants, including Purdue Pharma and Johnson & Johnson. Most of the defendants settled, while Purdue reached a blanket multibillion-dollar settlement with thousands of public and private plaintiffs as part of its bankruptcy proceedings. That left four defendants: pharmacy giant Walgreens, drug distributor Anda and drugmakers Teva Pharmaceuticals and Allergan. The bench trial is expected to last at least three months.
After a 45-minute presentation, Lembke faced cross-examination by lawyers for Teva and Allergan who attempted to get Lembke to admit their clients played minor roles in the opioid crisis and that any misinformation they disseminated — for example, that addiction rarely resulted from opioid prescriptions — was intended for "internal use" only.
Lembke pushed back, saying many of the internal documents were used to train sales representatives who visited doctors to convince them of both the safety of opioids and the necessity of treating pain seriously.
"This massive misinformation campaign stripped doctors of the true appreciation of the danger of opioid use," Lembke said.
Opioids were once rarely prescribed for long-term use. That began to change in the late 1980s, amid a growing recognition that chronic pain was a serious ailment undertreated by doctors. It became standard practice to treat pain as the "fifth vital sign." Experts largely consider this an overcorrection to what was once a real oversight by the medical community.
At the same time, many doctors and regulators became convinced addiction from genuine opioid prescriptions were vanishingly rare; that "drug-seeking" behavior was a sign that the patient was in pain and was being "under prescribed;" and that a patient who was prescribed opiates and became physically dependent on them wasn't experiencing addiction at all, but "pseudo-addiction." The degree to which these ideas became conventional wisdom is, with the benefit of hindsight, astonishing.
It's now generally accepted that Purdue Pharma played a huge role in convincing the medical community that large doses of opioids were safe for long-term usage. The extent to which other drugmakers, distributors and pharmacies helped create what San Francisco's lawyers have called a "paradigm shift" is still the subject of some debate, and is one of the key issues in the trial.
Lembke acknowledged the ideas about treating pain with opiates had been percolating for some time prior to the paradigm shift, and that Purdue was the primary driving force of the change. But, she added, "the defendants and others jumped on that bandwagon."
Teva attorney Wendy Feinstein in her cross-examination, pushed the idea that the FDA and DEA shared responsibility for the oversupply and overprescription of opioids. The FDA, she noted, approved Oxycontin and other powerful narcotics for the treatment of pain, while the DEA sets production quotas — limits on how many opiates can be produced by various manufacturers.
"There is lots of blame to go around," Lembke said.
State governments, too, played a role in the paradigm shift. California passed a number of laws, including the Intractable Pain Act in 1990 and the Pain Patients Bill of Rights in 1997, the latter of which required "doctors to advise patients who suffer from "'severe, chronic (and) intractable' pain that powerful narcotics are legally available that could grant them relief."
Both laws, Feinstein noted, were passed before Teva manufactured opioids.
Feinstein also cited evidence that drugs made by Teva, Actiq and Fentora represented a tiny proportion of the overall prescription opiates sold in San Francisco.
"You don’t believe the impact of the marketing of Actiq and Fentora was as big as the impact of the 15 leading opiates in San Francisco, do you?" she asked.
Lembke said that wasn't how she thought about it.
Later, Allergan attorney Hariklia Karis asked Lembke if she thought that doctors were more influenced by sales representatives than they were by the FDA-approved drug labels, which state warnings about the various dangers of taking a drug.
"Yes," Lembke said, adding doctors don't always have time to keep up with the latest research and are "much more influenced by peers and sales reps."
"I think it’s safe to say Allergen did influence key opinion leaders," she said.
Lembke's testimony will resume Wednesday.
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