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Pain and Addiction Expert Witness Comments on 72,000 Opioid Deaths in 2017

Last week, the New York Times reported CDC estimates of 72,000 opioid-related overdose deaths in the United States, in 2017. Unfortunately, a record breaking number, beating the number of deaths caused by guns, HIV, or car accidents.

Well, I wish the last time I wrote about the opioid crisis could have been the final time. It appears we are far from the end of this crisis. In fact, I began writing about this topic because it will go on for years and the litigation surrounding pharmaceutical opioids is just beginning.

Normally, I am not one to follow entertainment news. In fact, I view it is a distraction from far more important topics. Yet there I sat, just a few weeks ago, reading about the overdose of pop singer Demi Lovato. She has struggled with addiction from a young age and recently experienced a heroin induced overdose. Then last week the CDC released preliminary estimates of approximately 72,000 deaths caused by opioid overdoses, in 2017. This is a horrific plight on our nation. Chances are we all know someone impacted by this epidemic.

As I mentioned in a previous post, Experts.com has seen an incredible increase in the number of addiction medicine, substance abuse, and pain management experts marketing their services with us over the years. I started in 2010 and I’ve witnessed at least a five-fold increase in these types of experts.

The litigation against major pharmaceutical companies has also skyrocketed. In the last year we’ve seen cities, states, and counties bringing lawsuits against opioid manufacturers and distributors. The litigation against the manufacturers and distributors is encouraging if it helps stem the flow of opioid overdoses and death.

Based on this article in the New York Times, there are two reasons for the increase in opioid-related deaths: “A growing number of Americans are using opioids, and drugs are becoming more deadly. It is the second factor that most likely explains the bulk of the increased number of overdoses last year.” The article goes on to explain synthetic opioids, such as Fentanyl, is a major contributing factor to the rise in overdoses. The Times further elaborates:

“Strong synthetic opioids like fentanyl and its analogues have become mixed into black-market supplies of heroin, cocaine, methamphetamine and the class of anti-anxiety medicines known as benzodiazepines. Unlike heroin, which is derived from poppy plants, fentanyl can be manufactured in a laboratory, and it is often easier to transport because it is more concentrated. Unexpected combinations of those drugs can overwhelm even experienced drug users. In some places, the type of synthetic drugs mixed into heroin changes often, increasing the risk for users…”

High profile news stories followed by the shocking statistics from the CDC compelled me to reach out for insights from those on the front lines. Those who are treating patients with legitimate and often chronic pain, while also addressing substance abuse disorders. Dr. Adam Carinci is one such professional.

Addiction and Pain Management Expert Witness – Dr. Adam Carinci

Dr. Adam J Carinci, M.D. is a nationally recognized clinician, speaker and expert witness with over a decade of pain medicine experience. He is double-board certified in both anesthesiology and in pain medicine and maintains an active, full-time medical practice. Dr. Carinci is Chief of the Pain Management Division and Director of the Pain Treatment Center at the University of Rochester Medical Center and an Associate Professor at the University of Rochester School of Medicine.

As with previous articles, I posed a series of questions to Dr. Carinci and asked for his insights. Below are my questions and his answers.

Nick: For our readers, can you explain what constitutes a synthetic opioid?

Dr. Carinci: Synthetic opioids are man-made drugs that mimic the effects of natural opioids such as opium or heroin. Synthetic opioids act at the same opioid receptor in the body as naturally occurring opioids to induce pain relief, sedation and respiratory depression among other effects. Synthetic opioids are many times as potent as naturally occurring opioids. For example, Fentanyl is 100 times as potent as morphine (derived from opium).

Nick: Fentanyl is one of the synthetic opioids I’ve read about more in recent years. It’s mixture with heroin seems to be responsible for the increased deaths according to the New York Times. What are some legitimate medical uses for Fentanyl?

Dr. Carinci: The synthetic opioid agonist fentanyl is approximately 100 times as potent as morphine and is characterized by a rapid onset and short duration of action after a single dose. It is most commonly administered intravenously but may be given intramuscularly, transmucosally or transdermally. Fentanyl’s high lipid solubility contributes to its rapid onset because it readily crosses the blood–brain barrier. Fentanyl is used medically as a component of general anesthesia for surgery, as a sedative for procedural sedation and for chronic pain management.

Nick: Is there any data on how addiction begins?

Dr. Carinci: Addiction is a condition in which a person engages in use of a substance or in a behavior for which the rewarding effects provide a compelling incentive to repeatedly pursue the behavior despite detrimental consequences. Addiction is a biopsychosocial disorder. It is a susceptibility that is a confluence of a person’s genetics, neurobiology, psychological and social factors. Activity substances increase levels of dopamine in the brain. Dopamine is the molecular messenger of the brain’s reward center. It is what gives people the feeling of pleasure and reinforces behaviors critical for survival, such as eating, drinking and having sex. Different drugs tap into the dopamine reward system in different ways, some more potent generators of dopamine than others. There are a variety of factors that determine how addictive a drug can be, however, how rapidly each drug can get into the brain, and how powerfully it activates neural reward circuits are two critical factors. Thus, the combination of the person’s susceptibility and the potency of the drug combine to create addiction.

Nick: In your experience, what factors have led to the “opioid crisis” as we know it today? I realize this is very general, so a summary will suffice.

Dr. Carinci: The current opioid crisis has its roots in the late 1990s, where the use of prescription opioid pain relievers began to be prescribed at much greater rates. This subsequently led to widespread diversion and misuse of these medications before it became clear that these medications could indeed be highly addictive. Opioid overdose rates began to increase. In 2015, more than 33,000 Americans died as a result of an opioid overdose, including prescription opioids, heroin, and illicitly manufactured fentanyl, a powerful synthetic opioid. That same year, an estimated 2 million people in the United States suffered from substance use disorders. In 2016, synthetic opioids (primarily illegal fentanyl) passed prescription opioids as the most common drugs involved in overdose deaths in the United States. In 2016, over 42,000 drug overdose deaths involved opioids. Of those, 45.9% involved synthetic opioids.

Nick: What treatment options are available for opioid addiction?

Dr. Carinci: Medications, including buprenorphine (Suboxone®, Subutex®), methadone, and extended release naltrexone (Vivitrol®), are effective for the treatment of opioid use disorders. The most comprehensive approach should be combined medications with behavioral counseling known as Medication Assisted Treatment (MAT). Studies have shown that MAT Increases social functioning and retention in treatment.


 

There will certainly be more to come in regards to this crisis. If there are any experts you’d like me to consult regarding this topic? Any other expertise you’d like covered? If so, please leave a comment and we will continue to cover this story, both from medical and litigation perspectives.

 

 

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Opioid Crisis – An increase in addiction medicine and pain management expert witnesses.

In the nearly 8 years that I’ve been with Experts.com, I have noticed a massive increase in the number of addiction medicine and pain management expert witnesses marketing their services with our company. Between 2010, when I joined Experts.com, and today, the increase has been nearly five-fold.

Is this increase a surprise? Based on what we’re seeing in the news, the answer is no. The United States is experiencing an opioid epidemic. According to CNN’s Opioid Crisis Fast Facts, “more than two million of Americans have become dependent on or abused prescription pain pills and street drugs.” CNN further explains, “during 2015, there were 52,404 overdose deaths in the United States, including 33,091 (63.1%) that involved an opioid. That’s an average of 91 opioid overdose deaths each day.”

Just last week, I spoke to one expert witness who experienced an opioid-related death in his family.  The same day, hours apart, another expert began promoting his pain management and addiction medicine services on our site. This epidemic is impacting millions of families throughout our country. As a result of this epidemic, and much of the overdoses stemming from prescription medication, we are beginning to see significant litigation in the area of opioid-based pharmaceuticals.

Our Opioid Litigation Experiences:

Experts.com has processed more than a handful of expert witness referrals related to opioids. The cases have ranged from prescription abuse in family law settings to overdose issues resulting in wrongful death actions. Probably the most interesting opioid-related matter was as follows: general counsel for a mining company in a small town discovered the townspeople were using methadone at a rate approximately 5 times higher than the national average. Many citizens of the town were also employees of the mining company. They grew concerned about the potential liabilities of employees operating heavy equipment while ingesting powerful pain killers. The company decided to do some testing which triggered some privacy concerns and potential litigation. We have delivered toxicologists, addiction medicine specialists, and pain management professionals in dozens of different opioid-related cases.

Recent Litigation:

In the last few years, we have seen stories of both civil and criminal litigation related to the opioid epidemic, even before it was claimed to be a crisis. Here are a few of the cases you may want to follow:

Civil Litigation:

There have been many lawsuits against Purdue Pharma (maker of OxyContin) since the early 2000’s. As one article explains, more and more state and local governments are launching lawsuits against the manufacturers and distributors of heavy-duty pain medications. The frequency of these lawsuits is almost weekly.  In addition to Purdue Pharma, Cardinal Health, Teva Pharmaceuticals, Janssen, and others are targeted.

In July of this year, one of the lawyers, Michael Moore, who targeted tobacco companies in the 1990’s, began urging state lawsuits against the drug makers. By August, an Oregon County sued pharmaceutical companies for $250 million for allegedly persuading physicians to over prescribe opioids. As of September, Attorneys General in 37 states were urging insurance companies to do more to curb the opioid epidemic.

What can we deduce from the high-profile coverage of civil suits against the makers of pain killers? In my assessment, the worst is yet to come for the drug makers. This does not mean the drug makers are defenseless against the lawsuits. After all, there are others in the supply chain to be blamed: doctors, pharmacies, and the patients themselves. Over the long-term, the pain medication lawsuits are likely to be very costly for manufacturers and distributors.

Criminal Litigation:

For the sake of brevity, I’m going to ask you to assume that there is significant drug related crime and we’re going to skip the standard (possession and distribution) opioid cases. Where I have noticed a substantial increase, both in the news and in requests for expert witnesses, is in criminal prosecutions of prescribing physicians and pharmacists.

As CNN described, “doctors are increasingly being held accountable — some even facing murder charges — when their patients overdose on opioid painkillers they prescribed.” The article further explains that the DEA took action against 88 doctors in 2011 and 479 doctors in 2016. One of the doctors described has been convicted of murder. I see at least one new story a week where a doctor, or pharmacist, is being held responsible for the excessive amounts of pain killers prescribed.

The numbers described in the article above, combined with a more aware public, lead me to believe we’ll see even larger numbers of DEA actions against doctors when the 2017 statistics are available.

Other Legal Issues:

As you can tell, I focused on the two areas that I’ve noticed the largest increase in visible litigation. We have processed many other expert witness referrals associated with opioid issues. Many overdose cases are resulting in medical malpractice actions as well as actions brought by medical boards for ethical violations by doctors.  We often see the requests for expert witnesses relating to emergency medicine physicians, toxicologists, pharmacy and pharmacology experts, and more.

Opioid litigation may very well be the “tobacco” litigation of our time.  As such, we are confident that we’ll have more to write about and discuss in the future.