During years when the prescription opioid epidemic was spiraling out of control, corporate executives at the drug wholesaler McKesson sent at least two memos ordering employees to "refrain from using the word 'suspicious'" to describe escalating opioid orders from pharmacy chains.
The documents were disclosed this week as part of a landmark federal opioid trial now underway in West Virginia, one of the states hit hardest by opioid deaths.
The case focuses on claims by local officials in Cabell County and the city of Huntington. They say their community of roughly 90,000 residents was devastated by tens of millions of prescription opioid pills shipped to local pharmacies.
The trial's outcome is expected to establish whether drug distributors AmerisourceBergen, Cardinal Health and McKesson face liability nationwide for their alleged failure to curb the flow of prescription painkillers that were allegedly later abused.
The drug companies say they did nothing wrong and were merely filling legal prescriptions under close supervision from federal regulatory agencies, including the Food and Drug Administration, and the U.S. Drug Enforcement Administration.
Michael Oriente, an executive who oversees McKesson's opioid shipments, testified this week that company safety procedures were reviewed repeatedly by the DEA. He pointed to one instance where federal regulators inspected McKesson's drug distribution centers.
"They all passed the inspection," Oriente said.
But West Virginia Attorney General Patrick Morrisey described the conduct of the drug distributors as "outrageous."
"When you see the volume of pills that are flooding these small communities, to assert that somehow you didn't know ... this is an absurdity. Everyone knew," he told NPR.
McKesson has twice paid large settlements to the Justice Department for "alleged violations of the Controlled Substances Act," including a $150 million payment in 2017. The company admitted no wrongdoing.
Testimony and documents revealed during this civil trial have offered a rare and sometimes troubling glimpse of the inner workings of some of the largest corporations in America that dove deep into the opioid business.
At McKesson, for example, Oriente and other executives sent emails introduced at trial saying they were overworked and regularly struggled to meet their obligation to monitor shipments of highly addictive drugs.
Other documents in trial indicated that companies also continued to boost the threshold amounts of opioids that pharmacy chains could order without triggering alerts that had to be shared with federal officials, despite warnings from the DEA that they should heighten their vigilance.
Oriente testified that McKesson avoided using the word "suspicious" because they didn't want to prematurely judge pharmacies.
"Once you used that word you need to take action," Oriente said in court. "We just didn't want that label on a customer we deemed not suspicious."
Attorneys representing Cabell County and Huntington, however, argued in court that corporate executives were often callous about the potential harm caused by prescription painkillers shipped from their distribution centers.
One email shared among executives at AmerisourceBergen — made public for the first time during the trial — disparaged people addicted to opioids, describing them as "pillbillies" and referring to Oxycontin as "hillbilly heroin."
During testimony, reported by the news organization Mountain State Spotlight, AmerisourceBergen executive Chris Zimmerman voiced regret for sharing the email and said the company had an ethical culture of the "highest caliber."
But Amanda Coleman, who runs a shelter for homeless people in Huntington who struggle with addiction, said the email shows an "utter disregard for lives here. The dehumanization of words like 'pillbillies,' it's horrifying," she told NPR.
Public health officials say drug deaths in West Virginia surged again by roughly a third last year to more than 1,270 fatalities.
The federal opioid trial unfolding in the court of Judge David Faber in Charleston, W.Va., comes amid a national legal reckoning for Big Pharma, including drug manufacturers, distributors and pharmacy chains.
Another trial is now underway in state court in California with a separate state-level trial set to begin next month in New York. A federal bankruptcy court is also handling the reorganization of Purdue Pharma, the maker of Oxycontin.
Much of the blame for the opioid crisis has focused on Purdue Pharma and members of the Sackler family who own the firm and who have repeatedly denied any wrongdoing.
But many of America's largest corporations are entangled in the legal and public relations morass stemming from the opioid epidemic.
Government officials who have sued the drug industry say name-brand companies including CVS, Johnson & Johnson, Walgreens and Walmart created a growing pipeline of pain pills that led to widespread addiction and overdoses.
The companies all say they did nothing wrong.
More than half a million Americans have died since overdoses began to increase in the late 1990s, with a record 90,000 deaths last year. Most opioid deaths are now caused by an illegal form of synthetic opioid called fentanyl.
If companies are found liable for contributing to the epidemic, it could mean tens of billions of dollars in payouts to cities, small towns and states affected by the crisis.
Government officials say most of the cash would go to cover the costs of drug rehabilitation, therapy, foster care, housing and other programs that might ease the crisis.
"We need [the help]," said Herb Dickerson, who has been on and off pain pills, heroin and other drugs in Huntington for years and currently lives on the street.
"We're human beings. We're not animals. We just lost our way. We're just people looking for a help up," he said in an interview with NPR.