Two drug distribution companies controlled 60% of the prescription opioid market in the Baltimore area for more than a decade, sending hundreds of millions of addictive pain pills here with little regard for the havoc they would wreak, a city attorney said in opening statements of its long anticipated opioid lawsuit trial.

Displaying pictures of people splayed out on sidewalks, paramedics tending to them, and vacant houses littered with syringes on screens throughout a courtroom in Baltimore Circuit Court, Bill Carmody said the companies, McKesson and AmerisourceBergen, looked the other way while fueling “the worst opioid epidemic in America.”

Carmody said the companies ramped up opioid sales in the Baltimore area, overlooking “suspicious orders” called in by “pill mill” doctors, as the city was coming to grips with the heroin overdose crisis. In doing so, he said, they created a new generation suffering from addiction, people who went on to die at unprecedented rates when their subscriptions ran out and they turned to an illicit drug market inundated with deadly fentanyl.

“They flooded this city with hundreds of millions of pills of oxycodone. … They devastated the public health and safety of this city,” Carmody told a group of six jurors and six alternates selected Tuesday evening after two days of jury selection.

The city is asking the jury to determine that McKesson and AmerisourceBergen’s actions amounted to an “unreasonable interference with a public right,” which, in this case, he defined as residents’ right to health and safety, and to award “millions and millions and millions” of dollars in damages at the end of a trial slated to run through November.

Attorneys for the drug distributors said they were not to blame for the epidemic in Baltimore. They said doctors’ prescriptions, and Drug Enforcement Administration regulations, determined how many opioids were sent to Baltimore. They blamed the criminal element for bringing heroin and fentanyl to Baltimore, pointing to cartels, gangs and drug crews as the source of the crisis.

“Outside of this courtroom, outside of this lawsuit, when the city sits down at the table and tries to figure out what caused the opioid epidemic, there is not one mention of wholesale distributors,” said Andrew Stanner, an attorney for McKesson.

The companies’ lawyers also described themselves as pivotal, one-stop medicine shops for pharmacies and hospitals. They said opioids made up only a fraction of their business and that all of the pharmacies they dealt with were licensed by the DEA and Maryland. The attorneys added that the companies took seriously their responsibility to flag suspicious orders, but that those obligations only went so far.

“By saying we shipped too many pills, they’re saying we should’ve second guessed doctors in Baltimore,” said Robert A. Nicholas, an attorney for AmerisourceBergen. “Nobody wants that.”

Before they spoke, Carmody said he believed the companies would understate their responsibilities to prevent drugs from getting into the wrong hands.

“It doesn’t matter if you have a bad pharmacy,” Carmody told the jury. “It doesn’t matter if you have a bad doctor. If the pills aren’t getting into the city, what are you going to do?”

Before the trial began this week, other opioid manufacturers, distributors and pharmacy chains settled with the city for a combined sum of at least $402.5 million. The terms of the city’s latest agreement with opioid manufacturer Johnson & Johnson are being kept secret until the end of the trial against McKesson and AmerisourceBergen.

Carmody said the distributors made millions of dollars pumping opioids into the Baltimore area. Between 2006 and 2019, McKesson and AmerisourceBergen sent 320 million oxycodone pills to the area, he said.

“With the right to make money from the sale of opioids comes a responsibility. The responsibility is to comply with the Controlled Substances Act,” said Carmody, referring to a federal law requiring drug distributors to regulate for suspicious orders of pills and report those instances to the DEA.

According to Carmody, McKesson and AmerisourceBergen went to great lengths to avoid reporting orders to the DEA. He showed portions of emails and company policies.

In 2008, McKesson reached a $13.3 million settlement with the U.S. Department of Justice for violating the Controlled Substance Act. Shortly thereafter, a top official at McKesson compliance division wrote in an email that employees were to “refrain from using the word ‘suspicious’ in communications.” That wordage was later codified into a company policy manual.

“McKesson’s policy, you’re going to see in this case, was ‘see something, say nothing, so we don’t have to report it,’ ” Carmody told jurors, adding that McKesson did not report a single suspicious order in Baltimore between September 2008 and March 2012.

Stanner countered that McKesson told the DEA it would stop reporting suspicious orders because it was beginning a policy where the company would block the orders.

“Nobody’s trying to hide anything,” he said.

The “No. 1 customer for McKesson nationwide” was the independent Drug City Pharmacy in Dundalk, said Carmody, alleging that the company knew the pharmacy was filling prescriptions sent in from faraway pill mills and that drug dealers were selling pills in the parking lot.

Stanner presented photos of that pharmacy in 2011 and more recently, showing aisles with birthday balloons and baby supplies. Like all of the other pharmacies Stanner believed the city would accuse of wrongdoing, he said, Drug City was licensed appropriately. He added that the pharmacy is still in business today.

“This is not a place that’s causing Baltimore’s opioid epidemic,” Stanner said.

McKesson settled with the Justice Department again in 2017 for failing to comply with federal law, this time paying $150 million. That money went to the DEA, Carmody said, “it didn’t help the city of Baltimore.”

When the DEA started cracking down on other companies’ opioid distribution to Baltimore around 2012, AmerisourceBergen saw “an opportunity” to increase its share of the market, Carmody said.

The company’s lawyer, Nicholas, said there was a simple explanation as to why its sales accelerated dramatically in Baltimore around that time: AmerisourceBergen took over national distribution for Walgreens, which meant adding 34 stores in the city.

Carmody also accused AmerisourceBergen of “mocking” its responsibility under federal law to prevent opioids from ending up in the wrong hands, supporting his argument with emails from company officials.

In one such email Carmody showed jurors, an AmerisourceBergen employee reworked the lyrics to Jimmy Buffet’s “Margaritaville” to a song with a chorus of “Wasted away again in Oxycontinville.” In another email with the subject line “Oxycontin for kids,” there was a fake cartoon of a children’s cereal box with the brand name “Killogs” and the cereal called “Smack.”

Nicholas brushed those messages off as “a handful” of “embarrassing emails” that the city’s attorneys “plucked” from 20 years of company records.

Carmody said a former Baltimore police and DEA official would testify as an expert for the city, identifying for jurors suspicious orders McKesson and AmerisourceBergen should have reported.

The city will start presenting evidence Thursday, beginning with the testimony of Dr. Joshua Sharfstein, of the Johns Hopkins University School of Public Health. Sharfstein served as Baltimore health commissioner and Maryland health secretary, in addition to a stint as principal deputy commissioner of the U.S. Food and Drug Administration. Sharfstein also co-authored a book about the opioid epidemic.