The Robert C. Byrd United States Courthouse in Charleston. Photo by F. Brian Ferguson

In 2012, Doug Emma sent a concerned email to his bosses at Cardinal Health, one of the country’s largest drug distributors. He’d identified two pharmacies requesting suspiciously large orders of opioids. 

The company knew so little about what was happening at these pharmacies that Emma called them “black holes” in the email, which came up at the continuing trial of Cardinal and two other huge drug distributors in Charleston.

Both pharmacies were in West Virginia.

One was a small pharmacy in Van, a community of around 200 people in Boone County, that was filling prescriptions from Georgia. That pharmacy, Emma noted, had been cut off from buying oxycodone, the popular pain-reliever that drove the early opioid epidemic. 

But there was no indication that the same had happened to the second “black hole” pharmacy, a Medicine Shoppe in West Huntington that was experiencing “significant growth.”

In fact, it turned out, no one from the company had even bothered to investigate that pharmacy. Despite six separate requests from inside Cardinal Health to have someone visit the pharmacy to “validate” its suspicious growth, no on-site inspection had occurred, Emma wrote in the email.  

A lawyer for Cabell County showed the email Thursday at the Robert C. Byrd U.S. Courthouse  in downtown Charleston, where lawyers for the City of Huntington and the surrounding county are attempting to prove that the nation’s three major drug distributors — Cardinal Health, AmerisourceBergen and McKesson — are financially liable for their failure to stem the flow of millions of opioid pills into West Virginia, and the resulting epidemic that has claimed thousands of lives. 

Reporters are not given access to the courtroom, but the email was briefly shown on-screen in an overflow room while lawyers questioned one of the Cardinal executives who received it. 

Cardinal and the other distributors claim they are just middlemen, doing their best to ensure pharmacists can fill their prescriptions while diligently abiding by U.S. Drug Enforcement Administration regulations, which required distributors to report suspicious orders. 

Lawyers for the city and county are attempting to portray the “anti-diversion” efforts by the three distributors — efforts largely driven by increased pressure from the DEA to crack down on the epidemic — as haphazard and insufficient. 

In 2008, Cardinal Health paid a $34 million fine following a DEA investigation into its anti-diversion program, although the company admitted no wrongdoing. In 2012, the DEA temporarily shut down the company’s Florida distribution facility after finding the risk of diversion from the facility represented an “imminent threat” to the public. 

Earlier this week, lawyers grilled Michael Moné, a Cardinal executive who was responsible for implementing the company’s anti-diversion program in 2007. At the time, he had only three full-time employees on his team, as well as agents in distribution centers across the country who shared other responsibilities. It was a staff that he felt, at the time, was insufficient. He asked for more to “meet our regulatory obligations,” he said. 

He also redesigned the company’s program. “I improved the entire system,” he said. But that didn’t solve the problem.

The company continued to allow pharmacies to buy more and more opioids with little oversight. 

Cabell County’s lawyer, Mike Fuller, highlighted a single month in 2008, June, where nearly 800 transactions were flagged as suspicious in the company’s systems. But only two were reported to the DEA. 

It wasn’t an outlier. In other months that year, the company made no reports to the DEA. 

As a result, in Huntington, the quantity of opioids shipped to Medicine Shoppe from Cardinal’s Wheeling distribution center tripled between 2006 and 2012, according to a Mountain State Spotlight analysis of DEA data compiled by The Washington Post that accounts for various opioid formulations.

In 2010, the pharmacy was obtaining 18,600 dose units per month from all distributors — 3.7 times the national average.

Meanwhile, according to a retired DEA diversion investigator and expert witness in this case, Cardinal was ignoring red flags. Cardinal shipped at least two orders of oxycodone to the Medicine Shoppe in late 2010 “despite there being inadequately documented due diligence,” wrote James Rafalski in a report submitted to the court.

In his email, Emma recommended the Medicine Shoppe pharmacy in Huntington be scrutinized by a new committee designed to investigate “large-volume” purchasers — one of Moné’s improvements, made late in his tenure as head of the company’s anti-diversion division. Emma noted that the increasing orders could be attributable to new, nearby pain clinics and the shutdown of a “competitor in town.”

That competitor was SafeScript Pharmacies #6, a pill mill in downtown Huntington that was raided by the DEA after its owner was caught with numerous bottles of hydrocodone during a traffic stop. 

“When a DEA comes in and raids a pharmacy in a small town… where are those prescriptions now going to get filled?” Fuller asked Moné, who admitted that it would have been a relevant question for the company’s investigators, who had the power to halt sales or terminate a relationship with a pharmacy. 

An owner of the Medicine Shoppe, Angela Ronk, did not immediately return a request for comment. The state Board of Pharmacy’s website has no record of any disciplinary issues involving Ronk or her pharmacy.

Lawyers for Huntington and Cabell County have argued that drug distributors were more concerned with increasing sales than preventing drug diversion. 

In this case, Cardinal Health profited not just from sales to Medicine Shoppe — but also from a franchise agreement with the pharmacy’s owner. 

Medicine Shoppe International, which runs the chain of franchise pharmacies, is a subsidiary of Cardinal.

Lucas Manfield is a former Report for America corps member who covered business and economic development for Mountain State Spotlight. He has covered housing, health care and government accountability...