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Every morning, peer recovery coach Misty Dillon heads into work and has no idea how her day will unfold. 

In April, Dillon joined the Mingo County Quick Response Team, a four-person group that works with residents who are dealing with addiction. They help people who have overdosed recently and connect them to resources for treatment and long-term recovery.

But there are people struggling with addiction all over Mingo County. You can see them sometimes in magistrate court, on the third floor of the Mingo Memorial Building, where the response team is based. Or down the road at one of the local treatment clinics. Or in just about any of the small towns from Matewan to Delbarton, from Gilbert to Kermit. 

For the Mingo County response team, this work can seem like an uphill battle. But behind their efforts to address one of the largest public health epidemics in the state, there looms an even larger battle in the courts to hold manufacturers, distributors and state regulators responsible for their roles in the state’s addiction crisis. 

In 2018, Mingo County joined several West Virginia communities by filing a lawsuit against  various people and companies who the county says made the opioid crisis possible. Later that year, Mingo’s lawsuit was moved from the local state court to a federal court in Cleveland, Ohio. The federal system was moving opioid lawsuits from communities all over the country there to be litigated, because of the many common defendants and issues. Today, more than 60 West Virginia cities and counties have complaints there. They’re waiting alongside 3,500 other cases from all over the country.

Those complaints are waiting in line as a complex court system plays out, with thousands of lives and billions of dollars at stake. In May, the City of Huntington and Cabell County took the nation’s three largest drug distributors to trial at the federal courthouse in Charleston. After delivering their closing arguments in July, the city and county are waiting on U.S. District Judge David Faber to determine what, if anything, these companies owe them.

Attorneys who worked on the Huntington-Cabell case believe their work could have a huge impact on whether other West Virginia communities go to trial, and what successes they may have. But for places like Mingo County, with a much smaller population and far fewer resources to tackle the opioid epidemic, the legal process is not happening fast enough. 

“It’s taken over this town. The drug use has,” Dillon said.

A ‘Natural Reaction’ to Unprecedented Traumas 

Attorneys for Cabell County said last month that distributors AmerisourceBergen, Cardinal Health and McKesson helped ship more than 81 million prescription opioids to a community of less than 100,000 people over eight years. Those pills, the county argued, fueled an epidemic that resulted in 726 overdose deaths from opioids in Cabell from 2015 to 2020, according to the state Office of Drug Control Policy

Mingo County got about half as many pills, with only about a quarter of Cabell County’s population. From 2006 to 2014, distributors shipped more than 43.2 million pain pills to Mingo County pharmacies. 

“These drugs were diverted, misused, and abused, to the point where citizens of West Virginia, including the residents of Mingo County, lost their jobs, their health and even their lives,” attorneys for Mingo County wrote in the 2018 lawsuit.

Furthermore, these drugs “triggered resurgence in heroin use,” which is harder to regulate simply by restricting distributor actions and doctors’ abilities to prescribe. 

“It is hard to imagine the powerful pull that would cause a law-abiding, middle-aged person who started on prescription opioids for a back injury to turn to buying, snorting, or injecting heroin,” attorneys wrote, “but that is the dark side of opioid abuse and addiction which this complaint seeks to shine a light upon.”

Mingo County officials, lawyers for the county argue, bear the financial and emotional burden of responding to a public health crisis like the opioid epidemic: dispatching of emergency services, running drug treatment programs, investigations of overdoses, taking care of people who are dealing with addiction and transporting dead bodies.

“These costs reflect the natural reaction of leaders within Mingo County to traumas so unprecedented that no coping guidelines existed when they occurred,” the lawyers wrote. 

‘Situations You Just Can’t Explain’

Dillon and other members of the Mingo County Quick Response Team see these costs in their work every day. On a Thursday afternoon in mid-July, QRT members pull out of the Mingo Memorial Building parking lot in Williamson and head for the Gilbert area, about 30 miles away. 

They leave with a manila folder of printed emails and a cardboard box of naloxone, a medication to reverse the effects of an opioid overdose. Each email is a brief description of someone who has overdosed in the community. The naloxone is for community members and volunteer fire departments, who are sometimes called to administer the overdose-reversal medication when EMS can’t. 

On the way to Gilbert the team stops in Wharncliffe, where fewer than 800 people live. A small group is already gathered outside the volunteer fire station, sitting in lawn chairs while a radio rumbles in the background.

“What you see here is what you’re going to get on a call,” says fire department member Natasha Grimmett. She’s filling out paperwork for 10 more naloxone kits from the response team. Her young daughter sits at her feet, playing with bandages from a first aid kit.

“There’s situations you just can’t explain,” Grimmett said. “You cannot explain these things to people to make them understand it. Until you’ve seen it, you’ve dealt with it, you work with someone who’s out and completely unresponsive, turned purple … you don’t know about this.”

Janet Gibson, another fire department member, was the last to administer naloxone the weekend before the response team’s visit, to a woman who appeared to be experiencing an overdose.

“She was my age,” Gibson said. “In my class of 1989, I have lost 19 people.”

Gibson is also filling out forms for two new kits — she has a family member dealing with addiction and she wants to be prepared to save his life. 

“God forbid it ever be your own kid. But what if it was? Wouldn’t you want somebody to do everything?” Gibson said. 

Potential Outcomes of the Complaints 

When someone sues a company and a judge doesn’t dismiss it, most often they have two choices: they can go to trial or they can agree to settle. 

But lawsuits like Mingo’s against opioid distributors, manufacturers, regulators and prescribers are more complicated. There are dozens of defendants, and thousands of communities across the country have filed similar suits.

When Huntington and Cabell County went to trial, they were up against the nation’s three largest opioid distributors, AmerisourceBergen, Cardinal Health and McKesson. Even though the city and county also named manufacturers and pharmacies in their complaint, trying everyone at once would’ve made an already nearly  three-month trial much longer. So, U.S. District Judge Dan Polster, who is overseeing these federal cases in Ohio, agreed each type of defendant being sued would get a different trial.

In October, the first bellwether case against chain pharmacies will happen in Ohio. 

Some of the defendants named in Mingo County’s complaint no longer exist. That includes distributor Miami-Luken, the fourth largest distributor in West Virginia, which closed in 2019. They sent more than 22.5 million pills to Mingo County from 2007 to 2012, according to the 2018 complaint. 

A $26 billion settlement on the table from manufacturer Johnson & Johnson and the Big Three distributors also complicates matters for Mingo County. West Virginia opted out of this settlement amount, with state Attorney General Patrick Morrisey arguing the formula for who gets how much money is focused too much on population, and not enough on how hard the opioid epidemic has hit certain places.  

But the federal court, where 24 West Virginia counties and more than 30 towns and cities are waiting, still has to wait to see how many communities from other states agree to the $26 billion settlement. Then, Polster could decide whether to send West Virginia cases back to federal courts in the state, or even state-run circuit courts. 

Many of the opioid lawsuits, including those for another 60 West Virginia counties and cities, were never sent to federal court like the Mingo County case was. Instead, they’re in a state court mass litigation panel, which is scheduled to begin holding trials next spring. Before that, a panel of circuit judges will hold a status conference on the effort on Sept. 10, during which they’ll determine whether these communities can all go to trial at the same time. 

Then, there are cases like the ones brought by Gilbert, Williamson and Kermit — towns in Mingo County that filed their complaints before the county did. They were in the middle of requesting that they stay in their respective West Virginia circuit courts when they were moved to Ohio. If Polster was to return the cases to West Virginia for trial, Faber would have to decide whether these belong in federal or state-run circuit courts. 

How Mingo County and West Virginia Fit in Nationally

As Huntington, Cabell County and others in the federal system were preparing to go to trial this year, the United States saw roughly 93,000 people die from overdoses in 2020.

West Virginia saw at least 1,275 overdose deaths in 2020, more than the 878 deaths the state recorded in 2019. 

In Mingo County, Health Department Administrator Keith Blankenship said this represents only a sliver of the true problem, due to troubles with data reporting.

Because Mingo County runs along the Kentucky border, many people who experience medical emergencies like overdoses end up in hospitals across the river. There’s a lag in how that data reaches West Virginia reporting systems. 

Data from the neighboring counties of Logan and McDowell might paint a more representative picture. Both were behind Cabell County as the top three for overdose deaths per 100,000 people, according to the state Office of Drug Control Policy. For just a population of about 32,000 people, Logan County had nearly 50 opioid-related overdose deaths. In McDowell, which has roughly 19,000 people, there were just under 25 opioid-related overdose deaths.

Meanwhile, in Mingo County, a county with similar geographic composition and a 26,000-person population, the state drug policy office reported only nine fatal, opioid-related overdoses in 2020.

For the response team, not having reliable data on the area’s overdoses affects their work because it limits the number of people they can visit and invite to treatment. 

But for Mingo County as a whole, it limits the grants and funding they get to respond to the epidemic, because state officials are not getting a complete look at the crisis in Mingo County. 

If he were to compile a list of what Mingo County could use, trial or no trial, Blankenship said the needs are endless. The county needs more treatment facilities, or reliable transportation, to facilities in Huntington and Charleston, he said. They need more mental health workers to assist people coming out of treatment and returning to Mingo County. They need more naloxone, peer recovery coaches, Narcotics Anonymous meetings and sober-living places. 

“Grants are hard to come by, they really are,” Blankenship said. “A health department is only as successful as the person who writes their grants.”

It was a federal grant that came through the West Virginia Department of Health and Human Resources that got Mingo County its response team. 

“I see us getting a bigger team,” said Dillon, the peer recovery coach from the team. “It gets rough at times, we’ll definitely need someone.” 

Before Dillon was a peer recovery coach, she dealt with addiction herself. It started with prescription opioid abuse. When it became harder to access pills due to more stringent regulation, she turned to heroin. 

The local adult drug court program connected Dillon to a treatment facility in Greenbrier County, and to resources to sustain her recovery. Such programs, the county says,, the county says, are a locally-run response to a problem created by the companies that manufacture and distribute prescription opioids. 

Now, Dillon finds herself a part of another, similar county-run effort to undo the damage of the opioid epidemic. In the last four months, Dillon and the QRT have gotten more than 50 Mingo County residents into a treatment facility. They’ve intercepted criminal justice proceedings and gotten people who otherwise would be in jail into a detox center; they’ve made house calls to towns throughout the county and gotten people into rehab, days after an overdose. 

For those who aren’t ready for treatment, the response team members keep in touch on a weekly basis to make sure they’re doing OK.  

“I think we’re making a big difference,” Dillon said. “I have not seen this many people in rehab in years.”