All across America, thousands of localities have sued pharmaceutical manufacturers and distributors for their roles in the deaths of nearly half a million people from opioid overdoses. A federal jury in Cleveland found Walgreen’s, CVS, and Walmart liable for contributing to the drug epidemic in two Ohio counties. Walgreens recently settled a suit with Florida for $683 million. Now it is San Francisco’s turn, and the outcome may determine whether cities can sue companies in the pharmaceutical supply chain for the harm they have caused local governments, including paying for drug treatment programs and repairing damage to city property.

San Francisco’s trial is against Walgreens, Teva Pharmaceutical Industries (TEVA), and two other companies for fraudulently marketing opioids without “effective controls.” It began on April 25 after being transferred from a multidistrict case in Ohio.

The case has a long history. San Francisco’s City Attorney Dennis J. Herrera first sued Walgreens and a number of opioid manufacturers and distributors in a civil action in the U.S District Court for the Northern District of California in December 2018. His complaint claimed that the drug manufacturers were a “public nuisance” that violated California’s unfair competition and false advertising laws,” as well as the federal Racketeer Influenced and Corrupt Organizations Act (RICO).

Herrera’s suit claimed that “drug manufacturers’ deceptive marketing and sale of opioids is one of the main drivers of the opioid epidemic.” When the Sackler family’s Purdue Pharma, the nation’s largest producer of oxycontin, declared bankruptcy in 2020 after paying over $6 billion in a settlement with cities and states, Herrera’s lawsuit and thousands of similar efforts had to rethink their strategies. In 2020, his racketeering claims were dismissed by U.S. District Judge Charles Breyer. But, on April 8 of this year, Breyer denied all of the defendants’ other attempts at dismissal and summary judgment.

When deciding that the case could proceed, Breyer wrote a 100-page opinion that said that companies can be sued for creating a public nuisance and false advertising because they used misleading tactics to promote opioids, even though they knew about a thriving black market. He cited cases brought by the Drug Enforcement Agency (DEA) for failing to “maintain effective safeguards.”

He also found that marketing efforts “were designed to deceive both physicians and patients.” Doctors were paid millions for travel, consulting fees, meals and charitable contributions in order to increase the number of opioid prescriptions they would write.

Because of all the settlements, San Francisco’s is the first actual trial that names manufacturers, distributors and pharmacies for their roles in the opioid crisis. In his opening statement, David Chiu, now representing the City, said the entire opioid supply chain “was complicit in expanding the opioid market,” while ignoring its disastrous public health consequences. He said all the defendants “made false claims about the drugs’ safety” in order to market the drug to patients in pain. These efforts created a public nuisance as the city became flooded with prescription opioids while none of the defendants’ took action to prevent illegal use.

The trial has produced compelling testimony. On opening day, the City Attorney argued that Walgreen’s management “had pressured pharmacists into filling prescriptions quickly, leading employees to feel that they didn’t have time to scrutinize suspicious opioid orders.”

On May 9, Stanford Professor Dr. Anna Lumbke testified that Walgreens and the three other defendants “used misinformation to target doctors…Walgreens actively collaborated with Purdue to educate their pharmacists on the use of treating pain with opioids…Walgreens strategized with Purdue about how to get these messages out there.”

On cross-examination, she described internal documents that trained pharmaceutical representatives to convince doctors of opioid safety. She said the “massive misinformation campaign stripped doctors of the true appreciation of the danger of opioid use.”

On May 11, a former Walgreens warehouse manager said that so many opioids were ordered after 2010 that it felt like a “ticking time bomb.”

On May 12, a former Walgreens pharmacist testified that he felt pressured to “fill, fill, fill” prescriptions while working at a pace that was so fast she feared she might make “fatal errors.”

On May 16, a Walgreens pharmacist testified that Walgreens “tracked the prescription history of doctors, but did not make the information available to stores because it might “cloud” the judgment of a pharmacist about whether to fill an opioid prescription.

On May 18, the plot thickened again when an economist testifying for the City testified that he saw some “red flags” that made him skeptical about how legitimate more than half of the opioid prescriptions filled by Walgreens between 2006 and 2020 actually were.

Defendants argue that the blame for the crisis falls on Purdue Pharma, not on them. They also testified that all their marketing was approved by the federal Food and Drug Administration (FDA).

As the trial continues, the news about opioids keeps getting worse. The Centers for Disease Control and Prevention reported that U.S drug overdose deaths reached another record high in 2021 with 106,854 deaths. Walgreens’ website features a slick public relations campaign entitled “# It Ends With Us,” that explains all the things it is doing to “End the Epidemic.” It does not mention any lawsuits.