Medicinal morphine, derived from opium poppies, triggered the country's first major opioid epidemic in the late 19th century, with imports and consumption of medical opiates tripling between 1870 and 1890.
To doctors of the time, morphine administered with hypodermic needles was like a magic wand to quickly alleviate patients' pain — but overprescribing quickly led to addiction and growth of a black market for morphine diverted from the medical supply along with illicit drugs like opium and heroin, said David Courtwright.
A medical historian and retired University of North Florida professor, Courtwright testified Tuesday afternoon and Wednesday morning in Washington state's case against three of the country's largest drug distributors in a civil trial that got underway on Monday.
The state, in a lawsuit, has accused McKesson, Cardinal Health and AmerisourceBergen Drug of shipping vast amounts of oxycodone, fentanyl and other painkillers across Washington and failing to comply with requirements that they identify and report suspicious orders to the federal Drug Enforcement Administration, thereby contributing to the state's opioid epidemic.
Courtwright's testimony before King County Superior Court Judge Michael Scott seemingly drew a historical parallel between the introduction of injectable morphine with Purdue Pharma's launch of the opioid analgesic, OxyContin, in 1996. The drug was approved by the Food and Drug Administration a year earlier for treating chronic and acute pain not related to cancer.
The 2019 lawsuit filed by state Attorney General Bob Ferguson against McKesson, Cardinal, and AmerisourceBergen alleges the drug distributors contributed to the state's current opioid crisis by promoting and helping market Purdue's opioids to Washington's pharmacies and hospitals. Courtwright's testimony this week appears to draw on historical evidence of the close relationship between drugmakers and distributors to illustrate that point.
But the distributors' attorneys said in opening statements that the companies aren't to blame for people getting hooked on prescription drugs taken from the country's medicine cabinets, or for the influx of fentanyl brought into the U.S. by criminal organizations. The companies' attorneys have noted the DEA sets annual quotas for the manufacturing of opioids for legitimate medical and scientific use, and drug distributors have never come close to meeting or exceeding those quotas.
In his testimony, Courtwright said drug manufacturers and distributors have worked together before to promote new products and drive up sales.
"The epidemic in the late 19th century had a very strong medical component ... as was the case with the epidemic that started in the late 1990s and early 2000s," Courtwright said.
At the same time morphine addiction rose — the 1870s — is when articles started appearing in medical journals warning of the dangers of injected morphine, Courtwright said. By the early 1880s, there was an understanding in the medical community that if used injudiciously, morphine could lead to addiction "and all that goes with it," including overdose deaths, increased crime and other social problems, he said.
By the late 1880s, there were an estimated 150,000 addicts in the U.S. who were introduced to opiates by doctors, he said.
The years before the beginning of the 20th century saw the rise of "narcotic conservatism," the ethic that medical practitioners had to be careful in prescribing opiates and that they weren't appropriate for treating the kinds of pain that could be treated with alternatives like aspirin, which was introduced commercially in 1899, Courtwright testified.
Passage of the Harrison Narcotics Act in 1914 "really marks the beginning of the closed system of narcotic control in the U.S.," said Courtwright. It was the first time drugmakers, distributors, doctors and pharmacists had to register with the government and keep careful records with the goal of limiting opiate use to legitimate medical uses.
By World War II, "narcotic addiction in the U.S. hit an all-time low," Courtwright said.
In 1970, President Richard Nixon signed into law the Controlled Substances Act, which codified laws passed in the 1960s at the federal and state levels.
One of the act's provisions central to the case now being heard in Scott's Seattle courtroom says all registrants — manufacturers, distributors, doctors and pharmacists with access to controlled substances — have a duty to have in place controls and procedures to guard against theft and the drugs' diversion into the black market.
The act also defines "suspicious orders" as orders that are unusual in size, orders that deviate substantially from a normal pattern and orders of unusual frequency.
Narcotic conservatism — the idea that if people are not exposed to narcotics they cannot become addicted to them — was successful in reducing opiate addiction, Courtwright said. But that began to be challenged in the mid-1980s with a movement favoring more liberal prescribing of narcotics to treat non-cancer related pain, he said.
A number of early supporters Courtwright characterized as "revisionists" became paid speakers for drug manufacturers and manufacturers began financing "pain societies" and lobbying state medical boards to permit the use of narcotics for treating pain not caused by cancer, he said.
A "significant episode" in that effort was the launch of OxyContin in 1996, Courtwright said.
On cross-examination by Kim Watterson, an attorney for AmerisourceBergen who questioned Courtwright on behalf of all three companies, Courtwright acknowledged he hasn't interviewed doctors or pharmacists in Washington state and that by the 1980s the risks associated with opioids had been widely known for decades.
The bench trial is expected to last at least 12 weeks.
