It’s now up to a jury to decide whether a pair of drug distribution companies fueled Baltimore’s opioid crisis and whether to force the companies to pay the city $260 million.

Jurors are slated to begin deliberations Friday morning after lawyers for the city and companies, McKesson and AmerisourceBergen, gave closing arguments in the civil case Thursday.

Deliberations come on the back of a trial that spanned more than six weeks, featuring days of testimony, hours of videotaped depositions and scores of documents.

By sending hundreds of millions of painkillers to Baltimore from 2006 to 2019, the city alleges, McKesson and Amerisource overlooked their potentially devastating effects, helping breed a new generation of people suffering from opioid addiction who eventually died at staggering rates when they turned to heroin and potent fentanyl after their prescriptions dried up.

Lawyers for the drug distributors downplayed the influence of prescription pills they sold in fueling the crisis, instead blaming cartels, gangs and street crews for bringing the heroin and fentanyl, which they say is responsible for the scourge of addiction. The companies, their attorneys say, were merely providing drugs to fill prescriptions called in by doctors.

To win, the city must prove that the opioid crisis interfered with residents’ rights to public health and safety. Then it has to convince the jury that McKesson and AmerisourceBergen’s distribution of opioids was unreasonable, contributing to the public nuisance. It also has to prove the companies’ drugs ended up on the streets, though the city isn’t required to provide specific examples.

Jurors will first consider whether it is more likely than not that the companies did something wrong that contributed to Baltimore’s opioid crisis. Only if the jury finds the companies liable can it consider damages.

Baltimore is asking the jury to award about $260 million in compensatory damages, past and future, for money the city says it spent, or will spend, battling the epidemic.

Circuit Judge Lawrence P. Fletcher-Hill previously ruled out punitive damages in the case, limiting the amount of money the city could recover and giving the drug distributors a big win. Punitive damages can reach up to 10 times compensatory damages.

The city’s legal team hired William V. Padula, a professor of pharmaceutical and health economics at the University of Southern California’s Mann School of Pharmacy and Pharmaceutical Sciences, to calculate how much the opioid epidemic had cost the city.

He estimated that Baltimore spent at least $197 million over the last 13 years — an average of more than $15 million a year — combating the opioid crisis via its police, fire and health departments and the Mayor’s Office for Homeless Services. His calculations projected those agencies would incur $73 million in expenses related to the opioid epidemic from 2024 to 2029.

Dr. David W. Dowdy, an epidemiologist at Johns Hopkins University’s Bloomberg School of Public Health, also testified for the city. He estimated that there are more than 32,000 people with Opioid Use Disorder who are actively using opioids in Baltimore, roughly one of every 15 adults in the city.

Another city expert, Brendan Saloner, a professor at Johns Hopkins’ public health school, calculated that 83% of people with Opioid Use Disorder in Baltimore began their addiction by misusing prescription painkillers. In many cases, those people moved on to heroin and much more potent fentanyl when their prescriptions ran out, other experts said.

“It’s a path of opioid addiction here,” Bill Carmody, an attorney for the city, said in closing arguments Thursday.

Lawyers for the companies countered that heroin and fentanyl, not prescription painkillers, are the core of the problem.

“In 2000, Baltimore was the heroin capital of the world, and that continued for some time,” McKesson attorney Andrew Stanner told jurors.

The Drug Enforcement Administration in 2006 warned drug distribution companies of a growing epidemic of prescription opioid abuse. In a letter, they reminded the distributors of their obligations under the Controlled Substances Act to stand up regulatory programs designed to catch suspicious orders of drugs and to report those orders to the DEA.

Carmody said McKesson and AmerisourceBergen went to lengths not to report suspicious orders to the authorities.

McKesson in 2008 settled for $13.3 million with the DEA for failing its regulatory requirements. Following the settlement, a top regulatory official at the company sent out an email instructing employees to “refrain from using the word ‘suspicious’ in communications” because that triggered their requirement to report orders to the DEA and stop shipments.

Stanner said McKesson didn’t report suspicious orders for years because it enacted a policy in which it blocked all such orders.

Like all distributors, McKesson and AmerisourceBergen weren’t supposed to tell customers when they were nearing company-imposed limits on opioids. A top AmerisourceBergen official advised other employees of that in an email Carmody showed in closing arguments. “However,” the official wrote, “McKesson is using their willingness to provide that information to customers as a marketing strategy to prospect (AmerisourceBergen) customers.”

Carmody said AmerisourceBergen shared opioid limit information with one of its biggest customers, Walgreens. It supplied drugs and other medical supplies to 34 Walgreens pharmacies in Baltimore.

A former DEA agent, Ruth Carter, testified that both companies ignored glaring “red flags” that their opioids were ending up in illicit hands.

McKesson, for example, continued to send opioids to a Dundalk pharmacy despite knowing that the owner hired off-duty cops to catch people selling pills in the parking lot. It also continued selling to an East Baltimore internet pharmacy despite the DEA in 2005 subpoenaing records about its sales to that pharmacy.

Stanner and Robert Nicholas, an attorney for AmerisourceBergen, said the companies always believed they were in good standing with the DEA and abided by all regulatory requirements.

They chalked up rapid increases in opioid sales to “good faith prescribing” from doctors, noting that the DEA increased year after year a national threshold for opioid manufacturing in the 2000s, while the medical community was calling untreated pain an epidemic and not yet recognizing the brewing crisis of prescription drug abuse.

“We just deliver medicine so it’s there to be prescribed,” Stanner said.

Added Nicholas, “We only shipped to pharmacies that were licensed by the DEA and the state of Maryland.”

Carmody argued that the companies were understating their statutory responsibilities to prevent opioids from being misused and that Baltimore paid the price for their inaction.

A range of city employees spoke in court of the everyday toll of the epidemic: A fire official said the department responds to up to 6,000 opioid overdoses a year. A leader in the Department of Public Works’ Solid Waste Bureau testified to waste-laden blocks associated with opioid use. A health department employee described the agency’s efforts to combat the crisis, such as distributing clean needles to users.

Dr. Joshua Sharfstein, former Baltimore health commissioner and Maryland health secretary, said the city was “on the right trajectory” with declining heroin overdoses in the early 2000s “until something came along and knocked us off.” That something, he said, was the proliferation of prescription opioids in Baltimore.

“This is the biggest and most important case in the city’s history,” Carmody told the jury. “Do justice.”