The Washington PostDemocracy Dies in Darkness

Behind West Virginia’s opioid crisis, an addiction to money

In October 2005, the body of William “Bull” Preece, 45, was discovered in his rusted trailer in Mud Lick, W.Va. He had overdosed on oxycodone, a prescription opioid. His older sister, Debbie Preece, suspected foul play and resolved that Bull wouldn’t be just “another number, a statistic, in the overdose death toll. Somebody was going to pay.”

Debbie hired a lawyer, and the two discovered rivers of pills — Lortab, Percocet, Vicodin and more — coursing through the hollows of Appalachian coal country. They eventually learned that the Sav-Rite pharmacy in Kermit, W.Va., where Bull obtained his pills, had received 2.2 million hydrocodone and 78,500 oxycodone pills in the year after his death.

That volume was delivered to Sav-Rite by a single distributor, a company that purchases prescription pills from drug manufacturers, transports them to regional warehouses, and then delivers the medications to hospitals and pharmacies that ordered them. Over six years, from 2006 to 2012, distributors delivered 780 million hydrocodone and oxycodone pills to the state while 1,728 West Virginians fatally overdosed on those two painkillers.

“How did it happen?” asks Eric Eyre, a statehouse reporter for the Charleston Gazette-Mail. “How did 780 million painkillers spew into West Virginia and nobody said a word? How did millions of pills get dumped in small towns?” These questions had been driving Eyre since 2013, when, he says, he “stumbled into the middle” of Debbie Preece’s legal battle with the distributors. Soon he and his newspaper became part of the quest to get the facts.

Death in Mud Lick” is the story behind the gargantuan shipments of pills. It is about addiction to money as much as to pharmaceuticals. The book features an ecosystem of participants: Dr. Feelgoods and the pharmacists who blithely filled their stream of prescriptions; the pharmacies that existed cheek-by-corrupt-jowl with pill mills manned by doctors who didn’t even examine patients and pre-wrote prescriptions that were handed out by secretaries; distributors that failed to report to the Drug Enforcement Administration “suspicious orders” — when pharmacies’ painkiller purchases abruptly spiked from one month to the next — or did not do so reliably; the overwhelmed West Virginia Board of Pharmacy, which received suspicious orders from the distributors but did little; and the DEA, which had precious knowledge about distributors’ deliveries but resisted the efforts of the courts and Congress to pry the data out of the agency — until it no longer could resist. And then there was the state’s attorney general, who had conflicts of interest with one of the distributors and sought to suppress Eyre’s investigations. “Pablo Escobar and El Chapo couldn’t have set things up any better,” Eyre writes.

Yet it is the actions by distributors that lie at the heart of “Death in Mud Lick,” a highly readable account where events unfold in ticktock and the scenes are set cinematically. Eyre describes a balcony over a judge’s bench where in earlier trials “deputies stood, armed with rifles watching for trouble back when trials pitted union mine workers against coal companies.” In the legal tussle over the dumping of prescription painkillers, he shows us a baldheaded trial lawyer holding a Cuban cigar. “Was he going to light it? No, he was chewing it into a wet mess, spitting the juice into a Styrofoam cup.”

The middlemen “delivered the opioid epidemic,” as the author puts it in the book’s subtitle. (Technically, drug companies — which are referenced in the subtitle — are pharmaceutical makers; the subtitle applies the term over-broadly.) Over the years, those companies, most prominently McKesson, Cardinal Health and AmerisourceBergen, were in and out of court. They paid lots of fines but kept on trucking. In 2018, their chief executives gave sworn testimony before the House of Representatives Committee on Energy and Commerce: All denied contributing to the opioid crisis. Later that year, the committee released the results of an 18-month study. It found that distributors failed to conduct proper oversight of pharmacies by not questioning suspicious activity and not properly monitoring the quantity of painkillers shipped. The report also fingered the DEA for failing to monitor the flow of powerful prescription painkillers from manufacturers to sellers and for lax enforcement against distributors.

Eyre’s quest for answers culminated in a grand legal victory in the U.S. Court of Appeals for the 6th Circuit last June. The Gazette-Mail, its sister publication the Herald-Dispatch and The Washington Post successfully petitioned the appeals court to overturn the decision of a Cleveland federal judge to seal DEA data. When that data was released, the magnitude of the distributor activity became public: 76 billion oxycodone and hydrocodone pills had been shipped to towns across America from 2006 to 2012.

While “Death in Mud Lick” contains little commentary or interpretation, it raises lots of delicate questions. For example, how to reconcile the structural causes of addiction — poverty, low-paying jobs, social malaise — with personal agency? Many addicts, after all, used and stole drugs long before they showed up at the rogue pain clinics, as Eyre describes. And what about local dealers — don’t they shoulder significant responsibility for facilitating drug abuse and overdoses among their neighbors? As Eyre relays, the FBI arrested the Preeces in the 1980s for selling drugs out of a trailer parked beside the town hall and police station. When supplies got low, they hung up a sign: “Out of Drugs. Back in 15 minutes.” And the doctors? Couldn’t headlines just as easily have announced that doctors prescribed 76 billion oxycodone and hydrocodone pills over six years? Though focused on distributors, “Mud Lick” also shows why the blame should be widely diffused.

A powerful subtext of the book is the irreplaceable role of local journalism. Not simply to inform — an essential task in itself — but to help serve justice through investigation. Consistent with its “sustained outrage” ethos, the Gazette-Mail has been a tireless watchdog on the coal industry. Eyre was awarded the Pulitzer Prize in 2017 for “courageous reporting, performed in the face of powerful opposition, to expose the flood of opioids flowing into depressed West Virginia counties with the highest overdose death rates in the country.”

“Death in Mud Lick” is a product of one reporter’s sustained outrage: a searing spotlight on the scope and human cost of corruption and negligence.

A Coal Country Fight Against the Drug Companies That Delivered the Opioid Epidemic

By Eric Eyre

289 pp. $28