PARMA, Ohio - At Knuckleheads Bar & Grill, the subject on a sweltering Saturday afternoon was the drug crisis. More specifically, the recent disclosure that the CVS across the street received more pain pills - 6.4 million - over a seven-year period than any other drugstore in Cuyahoga County.
"Location, location, location," said Mike Gorman, 37, who was drinking and hanging out with friends. "It's right near the highway, which makes it easy to access" from Cleveland.
And there was the homeless encampment just beyond the CVS, over by the train tracks, behind the strip mall. It's popular with heroin users, the regulars at the sports bar said.
"It's a terrible thing, but I don't blame CVS," Gorman said, given the money to be made by pharmaceutical companies that sold the drugs and encouraged doctors to overprescribe.
The CVS in this white working-class suburb of Cleveland is a three-hour drive and, culturally, even further from the southern Ohio section of Appalachia that has become widely associated with the opioid epidemic.
But last week's revelation that drug companies saturated the United States with 76 billion pain pills over seven years shows that no corner of the country escaped the drug crisis. Two other drugstores in this city of 80,000 placed second and fifth on the Drug Enforcement Administration's list of Cuyahoga County locations. Wholesalers shipped opioids at 5.4 million and 3.7 million doses, respectively, to those. The list was disclosed by The Washington Post and HD Media last week.
Cuyahoga County and nearby Summit County soon will be at the center of the most important legal test of how much responsibility drug companies bear for the opioid epidemic. Barring a settlement, the two counties are scheduled to go to trial in October as the first case among the consolidated lawsuits brought by about 2,000 cities, counties, Native American tribes and other plaintiffs.
U.S. District Judge Dan Polster, who is presiding over the consolidated case in Cleveland, selected the counties to represent the legal arguments that other plaintiffs have made. The two counties are asking for billions of dollars from companies to help stem the crisis.
In a statement to The Post on Sunday, Mike DeAngelis, senior director for corporate communications at CVS, defended the company's actions.
"In the period of time covered by the ARCOS data (2006-2012), our shipments of hydrocodone combination products comprised only 2% of the prescription drugs we shipped to our pharmacies," he said. "As soon as the DEA reclassified these drugs as Schedule II in October 2014, we stopped distributing them immediately.
"The DEA possesses data on every single shipment of hydrocodone combination products we shipped to our pharmacies. It did not identify a single shipment to a single CVS Pharmacy in Cuyahoga or Summit Counties as improper."
In a court filing released Friday, lawyers for the two counties accuse some of the biggest names in the drug industry of creating a "public nuisance" that endangered the health of residents by failing to control the drug flow, even when they knew, or should have known, that some painkillers were being diverted to illegal use.
"There can be little doubt that the opioid crisis - the epidemic of opioid availability and use - significantly interferes with the public health and constitutes a public nuisance in both Cuyahoga and Summit counties," they argued in a request that Polster rule in their favor on that issue even before trial.
To bolster that argument, they offered an array of statistics that may be critical in the case. In 2016, they said, the death rate from pharmaceutical opioids in Cuyahoga County was 3.26 times higher than the national average. In 2017, county emergency rooms treated an estimated 9,191 people with drug-related health problems, a 21 percent increase over the previous year.
As the government cracked down on the diversion of pills to the black market, heroin and fentanyl took their place. By March 2016, two people died of a heroin or fentanyl overdose in Cuyahoga County every day, the lawyers alleged.
In Summit County, whose biggest city is Akron, the surge in overdose deaths was so rapid that the county medical examiner brought in a mobile morgue in 2017 to handle the bodies, the plaintiffs wrote.
The rate of infants born addicted to opioids there rose from 2.9 per 1,000 births between 2004 and 2008 to 13.6 per 1,000 births between 2011 and 2015, they alleged.
The defendants in the case include giant drug distribution companies such as McKesson, Cardinal Health, AmerisourceBergen, Walgreens and Walmart, and manufacturers such as Purdue Pharma and Mallinckrodt.
The companies have generally blamed the epidemic on overprescribing by doctors, overdispensing by pharmacies and on drug abuse by customers. The companies say they were working to supply patients in desperate need of pain relief with legal, highly regulated drugs.
"We maintain stringent policies, procedures and tools to help ensure that our pharmacists properly exercise their professional responsibility to evaluate controlled substance prescriptions before filling them," DeAngelis, the CVS spokesman, said Sunday. "Keep in mind that doctors have the primary responsibility to make sure the opioid prescriptions they write are for a legitimate purpose.
"Over the past several years, we have taken numerous actions to strengthen our existing safeguards to help address the nation's opioid epidemic that has resulted in a 30% reduction in the amount of controlled substances that our retail pharmacies dispense."
The public nuisance argument is the same one made by the state of Oklahoma in a seven-week trial against Johnson & Johnson that concluded last week. The state asked a judge to make the company pay as much as $17.5 billion over 30 years to clean up the drug crisis. Cleveland County District Judge Thad Balkman said he would rule around the end of August.
Another 48 states have sued drug companies and are lined up behind Oklahoma in a legal track that runs parallel to the enormous federal "multi-district litigation" in Ohio.
The intersection where CVS and Knuckleheads sit is typical for the outskirts of Cleveland, whose border is just a few hundred feet away. It has strip malls occupied by discount stores, and a mom-and-pop lunch counter threatened by the Burger King down the road.
Knuckleheads itself, like its patrons, appears transported here from Cleveland in the exodus to the suburbs that began decades ago. It is a squat stone building with signs promising cheap domestic beer, bar food and a Cleveland Indians game on TV. The men inside drain pints of Budweiser and Miller Lite between smoke breaks in the alley behind a black metal side door.
The pharmacist on duty at the CVS on Saturday declined to comment on the volume of pills sold there, citing company policy.
But Frank Cimperman, 58, Knuckleheads' owner, said he believes "it's only number one because of the highway, and because you can get a prescription filled there 24 hours a day."
Drugstores with easy access to highways have drawn authorities' interest in the past, including two CVS stores in Sanford, Florida, that were raided and shut down by the DEA in 2012.
At a Rite Aid in the Clark-Fulton neighborhood of Cleveland, an inner-city community of low-income whites and Hispanics, pharmacy manager Ben Swartz was surprised to learn that his branch ranked third in Cuyahoga County on the DEA database.
"Wow," said Swartz, whose store received 4.8 million pills between 2006 and 2012. But he said he is confident that in recent years stricter practices have been put into place.
"We vet all the prescriptions that come in here," he said. Extra measures, including verifying diagnoses with doctors, are used for about 1 in 10 prescriptions, he said.
"We look for prescribing trends," Swartz said. "If a doctor's giving everyone the same drug in the same quantities, we won't associate with them. We also scrutinize prescriptions for high strength and high quantities, and people using multiple pharmacies and multiple prescribers."
Preliminary data from the U.S. Centers for Disease Control and Prevention released last week showed that drug overdose deaths nationally declined about 5 percent in 2018, the first drop in decades. While deaths from fentanyl are skyrocketing, fatalities from prescription opioids are falling, the data show.
Residents on the blocks surrounding the Rite Aid spoke of a high rate of heroin use in the area. One person, who spoke on the condition of anonymity because he did not want to be identified as disparaging the area, said the sidewalk in front of an abandoned factory a block south was a "shooting gallery" until two years ago.
"We used to find hundreds of needles on the sidewalk here," he said. "But I haven't seen any in two years, so I think it's getting better."
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The Washington Post's Steven Rich contributed to this report.
GREENVILLE, N.C. - The Rev. Stephen Howard knew President Donald Trump's speech was going to be unsettling for his city and his mostly black church the moment he saw people had lined up at 4 a.m. Wednesday to get into the arena.
These were his congregants' neighbors and co-workers. Soon, they would be cheering for a president whom Howard and many of his flock at Cornerstone Missionary Baptist Church considered a racist. He knew he would have to say something.
"I'm not into politics, but I'm into speaking for people," he said.
Across town, Brad Smith, the pastor at a 192-year-old predominantly white Baptist church, got his first inkling that something had gone wrong when his wife returned home from the speech. She was there as an employee of East Carolina University, where the rally was held, and was shaken by the anger in the auditorium.
"It was bad," she told him. "Really bad."
Last week's campaign event in this North Carolina city was something different and more disturbing than the typical Trump rally. Before the president even stepped onto the stage in Greenville, the House had voted, mostly along party lines, to condemn as racist his repeated attacks on four congresswomen of color.
At the rally, Trump focused much of his frustration on Rep. Ilhan Omar, D-Minn., who is Muslim and a refugee. "Send her back! Send her back!" the people in the arena chanted in response.
The next day, Trump sought to distance himself from the chant. "I disagreed with it," he said in the Oval Office.
But in Greenville, the rally and its aftermath weren't so easily dismissed. Mayor P.J. Connelly put out a statement defending his town as "a place of compassion and acceptance." At Greenville's lone mosque, members spent a portion of Friday prayers talking about racism and Islamophobia.
Some of the deepest soul searching has taken place in churches, and much of it fell to pastors like Howard and Smith. In the days after the rally, they spoke with spouses, friends and fellow congregants about what the event had revealed about their president, their country and their hometown. Were the president's words and the anger they generated evidence of a moral or political failing? Did they say something deeper about their city? And did one of the biggest news events in Greenville's recent history merit a pastoral response from the pulpit Sunday?
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Trump's Greenville rally and the "Send her back" chants it inspired, divided much of the country, and Greenville was no exception.
Most of the congregants at the Unity Free Will Baptist Church in Greenville, where Jeff Manning, 55, has been the pastor for the past 29 years saw little wrong in the president's remarks or the chants that followed. They dismissed the cries of racism as more fake news.
On Friday evening, two days after the rally, Manning and his wife joined two families from his church for dinner. Soon, the talk turned to the president's appearance in Greenville, the growing rancor in the country and the aspect of the rally that had most struck his congregation.
"What I've heard is how upset people are with the language [Trump] used," Manning said. "He used the G-D word."
This, of course, was a violation of the Third Commandment and a serious matter in Manning's world, where the word of God is inerrant.
"Really?" said John Locklear, who had skipped the rally to attend Bible study.
"Children were there," added Adam Congleton, who watched it on a live stream.
With the exception of college and divinity school, Manning, 55, has spent his life in Greenville. His house, surrounded by soybean crops, is just yards from the modest, brick one-story where he grew up.
Over the past three decades he has seen his congregation grow from about 150 to 700 people. Three years ago the church built a sanctuary on a 50-acre plot, with plenty of room to keep expanding.
He has seen Greenville change, too.
"It's perceived as more progressive, but I don't see that as a compliment," Manning said.
He generally has liked Trump's policies: the economy doing well, the Supreme Court potentially inching closer to an abortion ban, and the president moving to protect the country's southern border.
Manning's biggest concern was the anger gripping the country, some of which he blamed on Trump.
"Christ got fired up at times," Manning said, "but he was always righteous in his anger."
Too often, he worried, Trump's fury wasn't righteous. And lately, that had led him to fret about the state of the president's soul.
On Sunday, he didn't plan to talk about the president's rally or its aftermath. Instead, he would discuss a verse from Philippians about embodying Christ-like qualities: "To live is Christ and to die is gain."
It was in this context that he found Trump wanting and wondered whether he was a "true believer." "I have grave concerns about his spiritual condition," Manning said of the president. "There's too much evidence against it. . . . I pray he will become one."
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The day after the rally, Smith's wife, Jamie, was back at work at East Carolina University, where she works in public relations, fielding wave after wave of angry calls from people who wanted to vent. Some were angry that the university hosted the rally. Others were upset that the school hadn't done more to defend the president.
"I'm having a rough time with what I saw last night," she texted Smith from her office.
He told her to take a deep breath and step away from the phone. To Smith, the chants at the rally were "disturbing" and "probably racist," but they didn't represent the Greenville that he knew. Smith's church, The Memorial Baptist Church, shared its stately, old brick chapel with a congregation that worshiped in Chinese and another that held services in Spanish.
Over the past decade, the three groups have grown closer, gathering for fellowship dinners and Bible studies.
Smith knew he had Trump supporters in his pews. One of his members regularly posted articles from outlets such as Breitbart on her Facebook page that he found objectionable or at least worrisome.
But he knew that, if he asked, that same woman would rush to the aid of one of the Hispanic or Chinese families that used their church.
"I could go to her and she'd be right there for them," Smith said. "It's baffling."
He was upset that Trump had chosen his city to hold such a divisive rally. And he wondered how the country had become so divided.
"Was it because a black president won?" he asked. "Maybe we weren't ready for it?"
Smith spent two days thinking about whether he should scrap his prepared sermon on Noah and the flood in favor of a speech focused on the rally and its aftermath.
"I am pondering how I can do it without getting political," he said.
When Sunday came, he took the pulpit and told the story of God's disappointment, the flood and the one good man he had chosen to save to start anew. The only mention he made of Trump's rally was a fleeting one.
"When those who protest to open borders and those who chant 'Go back home' can't seem to be on the same page, it is the love and grace and mercy found in the very body of Christ" that can mend divisions, he said.
This was the message of Noah's story: "To love God is to love all of us," he said. "It is hard to do, but it is beautiful."
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On Wednesday night, Howard, the pastor at the majority-black Cornerstone church, watched Trump's entire speech from his home. To most Americans, the people chanting "Send her back" were an anonymous mob of Trump supporters. To his congregation, they were, in some cases, fellow Christians worshiping just a few blocks away.
Howard, 51, came to the United States in the 1980s from Liberia and has experienced the country as both a black man and an immigrant with an accent. As a pastor at churches throughout the Southeast, he said he has learned that being asked, "Where are you from?" is not always a sign of harmless curiosity.
Just before Howard stepped to the pulpit, Trump fired off a new tweet accusing the four congresswomen of not loving America and demanding they apologize for the "horrible" and "hateful" things they had said.
Howard didn't see the tweet. On this Sunday morning, he looked out at his church's red pews. Almost all of the 150 worshipers were black.
There was an hour of singing, a pause for tithing and then Howard's sermon, which began with the 37th Psalm's advice "not to fret of those who are evil."
Howard reminded his congregants that God had delivered African Americans from darker periods in the nation's history. That salvation, he said, was even more reason to stand with Omar and the other congresswomen amid Trump's attacks.
"There's a message in [Trump's] message. It's not just for Ilhan Omar, it's for you and I. Because when it's over with her, they're coming to us to tell us to go back," Howard told his congregation.
The worshipers called out amens and shouted for him to "preach!"
"We can't go back," Howard continued. "What is it you want us to go back to? Second-class citizenship? Jim Crow? What is it you want us to go back to [former Republican senator] Jesse Helms?"
The Rev. Martin Luther King Jr. once called church services one of the "most segregated hours" in America. Decades later, King's quote still holds true. One of the biggest events to hit Greenville in decades was barely mentioned in at least two white churches here, where pastors were reluctant to blend politics and faith.
At Howard's church, the political, the spiritual and the moral were unavoidably intermixed. He promised his congregants that if they were steadfast in their faith, their deliverance from evil and sin would be heavenly.
And in a nod to the previous week, he noted, it could also be earthly.
"November 2020 ain't that far away," he said. "The wicked shall soon be cut off."