Over the past 20 years, hundreds of thousands of Americans have died from opioid overdoses. The number of deaths from prescription opioids is much bigger than the number of deaths from heroin sold on the streets. Further, the number of people who have died is just the tip of the iceberg. Millions more people suffer from addiction and opiate use disorder and it’s tearing families apart. More people have died from prescription opioid overdoses than the total number of American soldiers that died in Vietnam.

This national tragedy is the backdrop of a landmark lawsuit. The Simon Law Firm represented Brian Koon, who accused his doctor of recklessly overprescribing opioids. Koon v. Walden was one of the first juries in the United States to hold a physician accountable for overprescribing opioids. The jury’s 17.6 million dollar verdict has forced physicians to rethink how opioid medications are being prescribed. Brian Koon’s case result also changed the way opioids are being prescribed across the country.

A new podcast produced by the Simon Law Firm considers how the firm framed and tried the Koon case The podcast is called Results Don’t Lie and this five-part podcast series features trial attorneys Tim Cronin and Johnny Simon.

On a recent episode of another (of the three) Simon Law podcast series, The Jury is Out, Erich Vieth discussed the Koon case with Tim Cronin. Here are a few excerpts from that conversation.

Erich Vieth:

Assume that a person with chronic pain, goes to the doctor, for instance, back pain or neck pain. Assume that the patient has already tried a lot of conservative treatments, acupuncture, whatever, and nothing’s working. Then they go to a doctor and the doctor is thinking that surgery is not warranted. The doctor is considering prescribing an opioid pain pill. How should this then proceed?

Tim Cronin:

First and foremost, I would say that shouldn’t happen. Somebody with chronic pain like chronic back pain or neck pain should not be put on prescription opioids in general. I mean, there are purposes for prescription opioids, like post-surgically for acute pain that you give them for a few weeks in small doses and closely monitor it. If somebody has cancer, they can be useful or some things like sickle cell. But if somebody just has chronic pain that you don’t think can get treated surgically. In other words, they’re going to continue to have chronic pain to starting them on opioids, which is the most powerful, narcotic, most powerful pain pill you can give them is a decision to have them on it for the rest of their lives and never-ending increasing doses. So once you start because of tolerance, you’re going to have to keep increasing it.

It is guaranteed. You’re going to become physically dependent and a very high chance you’re beginning to become addicted. And you’re essentially deciding that a person is going to be on heroin and increasing doses for the rest of their life. Because prescription opioids are the same as heroin. They hit the same transmitters in your brain. They affect a person physically and psychologically in essentially the same way. So you really shouldn’t put a person with chronic pain unless it’s cancer pain, or some other very serious disease on prescription opioids. You should try the least dangerous pain pills first after you’ve tried everything else, physical therapy and all that stuff. If you do decide to give somebody prescription opioids for pain there are guidelines, now that make clear what, what already was the standard of care that you really shouldn’t escalate to over about 90 or a hundred morphine equivalent milligrams, or for more than three months.

Erich Vieth:

To clarify, you’re saying 90 to 100 milligrams, that’s a, that’s a maximum daily dose, right?

Tim Cronin:

Daily dose. Yeah.

Erich Vieth:

And just for comparison, my understanding from the appeal in the case, I almost fell out of my chair reading this 1500 milligrams per day. Is that right?

Tim Cronin:

Yeah. Over 1500 morphine equivalent dose.

Erich Vieth:

How, how is that possible? I know we’ll get, we’ll get into that, but isn’t, isn’t someone supposed to be dead when they’re taking that much.

Tim Cronin:

If you gave somebody that dose who hadn’t built up an increasing tolerance yet they would die very quickly, but he was escalated to that dose over the course of four and a half years where it started at 10 to 20 milligrams. And then it got up to about 50 to 60 on average after about the end of the first year. And then it quadrupled the next year and then it quadrupled the next year again. And so it just kept increasing and he built up this tolerance. That’s still at that dose. It was surprising that he didn’t die.

Erich Vieth:

How long we known that opioids are highly addictive,

Tim Cronin:

Forever. A lot of people don’t know heroin used to be able to be legally prescribed in the 19th century. And then they put a stop to that. Uh, you couldn’t prescribe heroin anymore because of how dangerous and addictive it was. And these are exactly the same. There’s not a difference. And then they came up with, you know, a couple of decades later, later morphine, and somehow morphine was allowed to be able to be prescribed by physicians. But oftentimes it was usually only used in like a surgical setting. And it was never used for just give to patients outpatient for chronic pain. And then they started inventing these synthetic opioids. So some opioids are just a natural byproduct of the poppy, which is like heroin and morphine. And then there are ones that are synthetic opioids, which are created in a lab to operate the exact same way. And despite this campaign to flood medical journals with false information about the addictive nature of opioids, every physician should have known that they knew what these things were. The risks have never changed over time. So they all should have known. They’ve always been scheduled two narcotics by the DEA, which is defined as high propensity for abuse and dangerous.

Erich Vieth:

Once you’re addicted, you’re rather desperate to get more and more of the stuff. Let’s say your doctor puts the brakes on and says, I can’t give you more. I assume there’s a lot of folks that would probably just go out and try to find another doctor and not tell Dr. A about Dr. B. And so the pharmacy might be filling multiple prescriptions. Is there something in place to prevent that?

Tim Cronin:

So that’s an excellent question. First of all, the prescription opioid problem has bled into and increasingly caused the heroin problem. Our country is seeing a lot of physicians starting to recognize or get scared about lawsuits. Once the epidemic started exploding, many just pulled their patients off of opioids. And then we started to see an increasing heroin problem. A lot of the people who end up addicted to heroin got hooked on prescription opioids and then couldn’t get them anymore. And then started getting heroin off the street for even cheaper. That’s one problem that we have. If you’re going to take a patient off of opioids, you need to closely oversee them and taper them down and also get them help from an addiction treatment facility. That’s the right way to do it. But one of the things you mentioned is, people getting prescriptions from different sources or jumping from one doctor–it’s called doctor shopping, which is a big problem. And every state in the country has a prescription pill monitoring program in place to prevent that kind of thing, except for one state. Do you want to take a guess what that state is Erich?

Erich Vieth:

Uh, I’m afraid to guess. Is it Missouri?

Tim Cronin:

Yep. It’s Missouri.

Erich Vieth:

What has happened on a nationwide basis with regard to litigation on these issues, since your verdict was upheld on appeal in 2017. Are there a lot more cases being brought?

Tim Cronin:

Once that verdict hit, it got national coverage that it started being taught in seminars. It led to a lot more lawyers advertising for and handling cases just like this. So we’re not the only ones. There are attorneys throughout the country that are handling them. I think far more importantly, it has actually led to a positive change where [problem of over-prescribing] is happening less often. That verdict got taught to risk managers and major hospital systems all over the country immediately. It started getting taught at continuing education courses to physicians. Most physicians stopped doing it and started prescribing much more carefully. And institutional healthcare providers started putting in policies and procedures and monitoring programs to monitor physicians about the amount of opioids that we were prescribing and having a system in place to follow up about it. If amounts got too high, new policies curb this kind of thing from happening. My hope is that in the future, there won’t be any cases about this, because it will stop happening.