Main Street in McArthur was desolate on a sunny Wednesday in late October. A “Welcome to McArthur” sign planted outside the local cemetery felt like dark humor. Ryan Cain, a police lieutenant in the town, says the Hotel McArthur, a dingy apartment-style building with sheets for curtains that sits across the street from the local courthouse, is a known haunt for people to use drugs. “We used to go outside all the time,” Cain says. Now children don’t play in the park, because parents are worried about finding needles.

Cain, who grew up in the neighboring town of Ray, says that about 20 people he went to school with have died from a drug overdose. A friend he grew up playing sports with fatally overdosed on a fentanyl patch, a form of pain reliever. He recounts the story of another classmate who died. Her children, ages four and six, had just returned home from a day with their father. “They went to go get into bed and be excited to come back to Mom,” Cain says. “She was dead in the bed from an overdose.”

Nearly every call Cain responds to is related to drugs. The drug users who haven’t died, Cain says, “are now out stealing almost daily.” Elderly men sell their pills in exchange for sex with girls in their twenties or younger. He can’t remember the last time the jail had free beds. When nearby Fairfield County opened a new 200-bed jail, it took just 30 days for it to fill.

Across the street from the sheriff’s office, in a basement office with no windows, Vinton County prosecutor Trecia Kimes-Brown is also battling the fallout from the opioid epidemic. Since 2013, Kimes-Brown has handled mounting arrests connected to painkillers: drug possession, drug sales, murders, homicides, theft, driving under the influence. She regularly fields calls in the middle of the night from police officers wondering where they can bring someone who’s just been arrested. She knows the jails are full, so she mentally scrolls through all the current inmates to decide who is the safest person to release in order to free up a bed. She can’t always make room. On a recent Saturday, police arrested a local woman who tested positive for methamphetamine. But not a single jail across 23 counties — a range spanning the width of Ohio — had space for her.

One night in January 2017 still haunts Kimes-Brown. On a Friday, she released a man who had detoxed from drugs and alcohol after two weeks behind bars in order to make room for another offender. She instructed him to report for rehab after the weekend. That night, he tried to kill himself by overdosing. On Saturday, he tried again. On Sunday, he succeeded. “Had I kept him locked up for three more days, he would probably be alive,” Kimes-Brown says. “It has to change. It has to change.”

“I find that blame falls at the feet of the people who knew better.”

Vinton County, which has a population of 13,000, is currently spending $600,000 per year housing people in jail and an estimated $500,000 per year on foster care for children who have been abused or neglected because of the epidemic. That’s about a quarter of the county’s annual $4.2 million general revenue budget. Ohio recently changed its sentencing laws so that people who commit Class 4 and 5 felonies — thefts under $1,000; buying, selling, or using drugs — cannot be sent to prison, which the law used to permit. Yet the state has not provided the county with any additional funds to house those arrests locally, so offenders are released back into the community, often with no place to go, because the county has no homeless shelter. Sometimes they are given a GPS monitor, which the county usually has to pay for, because most offenders are indigent. Without jail or rehab beds available, minor felons simply go “wherever,” Kimes-Brown says. The county courthouse has become a revolving door, the same offenders entering and leaving week after week.

Vinton isn’t an unusually poor county. A median household income of around $41,000 per year and a 5.8 percent unemployment rate place it in better economic shape than many other rural areas hit by the epidemic. But the county has no hospital, no detox facility, no inpatient rehabilitation center, and no mental health facility. Most rehab centers in the area require no drug use for 72 hours prior to entry, a difficult requirement for substance abusers to meet when there’s no place to incarcerate people and keep them away from drugs after an arrest.

To be a prosecutor is to be in the business of assigning blame. For her own part, Kimes-Brown believes we are each personally responsible for our actions. But when it comes to the opioid epidemic, she says, “it’s hard to blame that 15-year-old girl using meth.” Or the 21-year-old who got hooked on painkillers after his doctor over-prescribed them. Or the young adult who was shot up with heroin by his father when he was barely a teenager. “I find that blame falls at the feet of the people who knew better,” she says.

To Kimes-Brown, those responsible include the pharmaceutical manufacturers and distributors, the DEA, and the federal government as a whole. “I think there’s responsibility to go around,” she says. (The DEA declined to comment.) But she singles out the pharmaceutical and distribution companies that have profited from the addictive properties of the medicines they sell. “They created this storm for us that we’re living with,” she says. “They’re not remedying it.”

Kimes-Brown met Farrell in the spring of 2017, soon after the city of Huntington filed its case. Farrell’s Appalachian roots and his mission to take on the makers and sellers of opioids persuaded Kimes-Brown to propose that her county also file a lawsuit with him. “It’s really nice to see someone carry that crusade for Appalachia,” she says. A West Virginian by birth, Kimes-Brown grew up in a town of 500 people near Huntington and felt a kinship with Farrell. And she knew there was no way Vinton County could confront the pharma players on its own.

As with the other plaintiffs, the county agreed to give Farrell and his firm a contingency fee of about 25 percent of any monetary award in exchange for handling the suit. Assigning blame matters, as it would for any prosecutor, but so does the money for a small community drowning in opioids. “The purpose of the lawsuit is the abatement of the nuisance,” Kimes-Brown says. “With the lawsuit funds, my county will be able to determine how we fix the problem.”

The success of the National Prescription Opiate Litigation hinges on whether a judge and jury will agree that the companies’ business practices qualify as a public nuisance. In the lawsuit’s 343-page complaint, the plaintiffs argue that drug distributors violated the rights of public citizens when they dumped pills into communities “without following the controls that should be in place,” says Hunter Shkolnik, a New York plaintiffs’ attorney allied with Farrell.

The Controlled Substances Act of 1970 requires companies to track every single Schedule II narcotic, a category that includes OxyContin, Percocet, and other prescription variations of opium. If demand spikes, distributors “have a duty to perform due diligence and investigate before they ship it,” argues Peter Weinberger, a Cleveland-based attorney on the litigation team. Failing to do so, the plaintiffs argue, created the public nuisance we now know as the drug epidemic.

But the lawyers need to provide proof. In public nuisance cases against gun manufacturers, defendants have argued, often successfully, that they didn’t cause the ultimate harm because they didn’t pull the trigger. Albert Lin, a professor at the UC Davis School of Law, says the drug companies and distributors could argue that the parties responsible for the epidemic are the people taking the drugs themselves — a defense that could resonate with juries. “The people who are most directly affected here don’t have what we call clean hands,” says Richard Ausness, a professor at the University of Kentucky College of Law.

Farrell and his team believe they have more than enough evidence to show that drugmakers and distributors created a public nuisance through their actions. The introduction of OxyContin in 1996 was followed by an aggressive marketing campaign that encouraged physicians to broaden the conditions for which they prescribed opioids. Purdue, for example, helped doctors overcome a longtime fear of hooking patients on opioids through office visits, free meals, and funding pain foundations and physicians to deliver the message that untreated chronic pain constituted an epidemic and that the addictive properties of opioids were a “myth.”

“We told all the physicians they had to treat pain, but we didn’t give them any tools.”

The same year OxyContin hit the market, the American Pain Society — an advocacy organization funded by pharmaceutical companies — began a campaign to expand medical care for pain based on the idea that it is the body’s “fifth vital sign,” along with traditional markers like body temperature and blood pressure. In 2001, the Joint Commission — a federal agency that sets medical practice standards — introduced an updated approach to patient care stating that doctors should always address pain; not doing so, the commission found, meant doctors weren’t doing their job appropriately. Soon, patients were rating doctors on how well they addressed their pain, a score that insurance companies used to help determine whether to include a physician on their plan.

“We told all the physicians they had to treat pain, but we didn’t give them any tools,” says Janet Woodcock, who directs the Center for Drug Evaluation and Research at the U.S. Food and Drug Administration. That could have included cognitive behavioral therapy, acetaminophen, and, Woodcock says, “a stiff upper lip,” counseling patients to tolerate the pain and tough it out a bit. But what they had were opioids — lots and lots of opioids.

Health care providers wrote 259 million prescriptions for painkillers in 2012, enough for every American adult to have a bottle of pills. The industry continued to feed that demand. Many physicians were clueless about the addictive nature of the drugs they were now prescribing. Others began over-prescribing them, often through “pill mill” clinics designed solely to make money from dishing out unnecessary prescriptions, many of them to people who had already become dependent.

When the DEA finally began taking action against the pill mills, cutting the supply of prescription painkillers, people who’d become addicted to opioids needed a new fix. Heroin — a cheaper opiate that’s available on the streets — was waiting. The number of heroin users in the United States rose steadily over the past decade; in 2016, nearly 1 million Americans admitted to using the drug, up from about 370,000 in 2007. In 2006, about 90,000 Americans used heroin for the first time; by 2016, that number had reached 170,000. Fentanyl, a lab-made opioid both cheaper and more powerful than heroin, eventually entered the illegal drug market, often disguised as a prescription drug or mixed with heroin to stretch profits.

Distributors, however, insist they have been following proper protocols all along, reporting and halting suspicious orders. “We refuse service to customers we deem as a diversion risk,” said Gabe Weissman, who leads communications at AmerisourceBergen, in a statement provided to OneZero. Weissman also says the company provides daily reports on opioid orders to the DEA. A representative from McKesson pointed to pages on the company’s website about its anti-abuse initiatives but said the company would not discuss ongoing litigation. Cardinal Health did not respond to a request for comment.

In a statement to OneZero, John Parker, who handles communications for the Healthcare Distribution Alliance, a trade organization that represents wholesale distributors, including the big three, vehemently opposed the allegations. “The idea that distributors are responsible for the number of opioid prescriptions written defies common sense,” he said. “Those bringing lawsuits would be better served addressing the root causes, rather than trying to redirect blame through litigation.”

Still, notes Lin of UC Davis, public nuisance statutes also consider negligence and wrongful conduct. Even if the companies did not explicitly know they were causing an addiction epidemic, Lin says, the law also considers what defendants “should have known.” The sheer volume of prescriptions — which the plaintiffs will argue far exceeded what should have been reasonable medical use — could prove that point, though drugmakers have denied the allegations as well. “The allegations made against our company are baseless and unsubstantiated,” reads an unattributable statement provided to OneZeroby Janssen Pharmaceuticals.

Juries may decide otherwise as the inner workings of the companies in question are brought to light. Correspondence made public through a complaint filed by Massachusetts in January indicates that the Sackler family, who own Purdue, knew the company’s products were addictive. “We have to hammer home on the abusers in every way possible. They are the culprits and the problem. They are the reckless criminals,” Richard Sackler, Purdue’s CEO from 1999 to 2003 and, later, co-chairman of its board until 2018, wrote in a confidential email. (Sackler’s 2015 deposition taken for a lawsuit filed by Kentucky, settled in December 2015, is also now public.) Farrell says that “we have conducted the same depth of discovery against all of the defendants.” If other drug companies left a similar trail of disturbing exchanges, then the case could be made that not only should they have known better, but also that they did know better.

Other points in the Massachusetts filing include repeated instruction by the board, which includes several members of the Sackler family, to increase the number of sales reps marketing opioids to physicians, despite existing reports from Purdue staff relaying concerns about abuse and the diversion of pills from pharmacies to the street. Purdue declined to comment but pointed to its motion to dismiss the suit, saying Massachusetts “set forth a misleading narrative in an attempt to litigate this case in the court of public opinion.” The motion points out that most people who die from overdoses in the state have heroin or fentanyl, “not Purdue opioids,” in their bloodstream.

The National Prescription Opiate Litigation also accuses the defendants of racketeering, which is prosecuted under the 1970 Racketeer Influenced and Corrupt Organizations Act, or RICO law. Contrary to common belief, RICO law is not only about prosecuting the mafia. Rather, racketeering is a broadly defined crime that includes copyright fraud, mail fraud, wire fraud, and even removing serial numbers from certain kinds of goods. To prove a RICO violation, plaintiffs must show a pattern of activity and some form of enterprise used to perpetrate the crime.

RICO violations don’t always involve violence, and they don’t need to be prosecuted in criminal court. The lawsuit asserts that the distributors and manufacturers engaged in racketeering — otherwise known as fraud — that caused injury and cost money. For example, the companies allegedly created or funded advocacy groups that lobbied medical authorities to call for an expanded use of painkillers. Because the case is in civil court, the plaintiffs needn’t prove their point beyond a reasonable doubt. They only need to provide enough evidence to slightly tip the scales in their favor.

Still, even if the defendants did violate the law by, say, failing to report alarming amounts of drug sales to the DEA, that doesn’t mean cities and towns deserve a financial reward. “They’re not the group that the law is intended to protect,” Ausness says.

All the legal theorizing could be irrelevant if the parties agree to settle. Judge Polster called for such an ending when the hundreds of complaints were first consolidated. Moore is hoping for the same outcome, with a settlement offer that encompasses both the state-level cases and the MDL. “A settlement,” Moore says, “is so much better than getting into a fight and seeing who wins.” (The first state trial of Moore’s lawsuit is scheduled to begin in May in Oklahoma.)

None of the plaintiffs or defendants have publicly discussed any estimated dollar amount, though Moore believes it “won’t come near” the $246 billion settlement with the tobacco companies. Whatever the amount might be, both Moore and Farrell are adamant that any settlement must include complete disclosure of the documents they’ve acquired. “I don’t think any resolution of this case is possible,” Farrell says, “without a full accounting and transparency [about] what gave rise to this epidemic.”