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止疼药瘟疫愈烈,药企巨头麦克森无辜还是有罪?

Erika Fry 2017年07月19日

在美国西弗吉尼亚,饱受药品滥用打击的社区将麦克森告上法庭。疑点重重的订单直指一场规模浩大的瘟疫。


在美国西弗吉尼亚,饱受药品滥用打击的社区将麦克森告上法庭。

去年秋天一个晚上,西弗吉尼亚麦克道威尔县本地新闻提到滥用止疼药危机日益严重,电视前的警长兼会计马丁·韦斯特终于忍无可忍。新闻里提到的内容让他感到极为愤怒。

62岁的韦斯特同时担任县里的牧师,因而目睹过很多惨剧。他在麦克道威尔县出生成长,活了一辈子却只能眼睁睁看着家乡不断衰退。韦斯特年轻时,麦克道威尔县还是个繁荣的小地方,位于西弗吉尼亚最南端却是整个州的产煤中心。1982年之前韦斯特一直在煤矿工作,之后下了岗。29岁时他当选县治安法官,一当就是27年,后来当选为警长。他负责过很多案件,发现越来越多当地人因滥用药物而一蹶不振而且陷入赤贫,滥用止疼药之风逐渐蔓延。

The company is facing lawsuits from devastated communities in West Virginia.

One evening last fall, Martin West finally reached his breaking point. The sheriff and treasurer of McDowell County, W.Va., was watching the local news when a report about the deepening opioid crisis came on. What he learned that night incensed him.

West, 62, is also a pastor in his community, and he has seen a lot of suffering. He was born and raised in McDowell County, and over his lifetime he’s borne witness to its inexorable decline. In his youth it had been a prosperous place. The southernmost county in West Virginia, it was at the heart of what was then the state’s booming coal country. West himself worked in the mines until 1982, when he was laid off. At 29 he was elected to be a county magistrate. And for 27 years, before he was elected sheriff, he presided over court cases—ones that increasingly involved the stories of lives undone by drugs and poverty, and of an opioid epidemic taking root.

西弗吉尼亚查尔斯顿南部贝拉,运输煤炭的火车隆隆而过。图片提供/摄影:马特·艾希

过去十五年间,麦克道威尔县因滥用处方止疼药死亡的人数越来越多,在美国所有县排名第二(仅次于旁边的怀俄明县)。韦斯特认识的很多正常人都卷入其中。有些人因为失业开始嗑药,有些人因为受伤吃止疼药上瘾。他认识有些一家人全因滥用药物死亡。身为牧师,他安葬了不少受害者。作为警长,他也抓了不少人。作为会计,他发现根本没有资源改变现状。县里一个戒除药瘾的康复中心都没有,也没有足够人手处理所有与药物相关的投诉。(去年他手下的15个人解雇了5个。)“每个星期都有人死亡,”韦斯特说。“让人非常遗憾。”

但最让他愤怒的就是那晚新闻中提到小镇沃尔,麦克道威尔县底下一个只有800人的小镇。新闻里解释了为何沃尔会出现大量处方止疼药,数量远超当地人合理安全的使用水平。维斯特得知,止疼药是由几家规模巨大盈利极高,负责在全国销售处方药的大公司送到沃尔的。

Over the past decade and a half, McDowell has lost people to prescription opioid overdoses at a higher rate than any other county in America but one (its neighbor, Wyoming County). And West knows plenty of good folks who have been caught up in the epidemic; those who lost their jobs and turned to drugs, and others who were injured and then got hooked on the pain meds prescribed to them. He can cite whole families who have died in the epidemic. As a pastor, he has buried many of its victims. As sheriff, he’s locked them up. And as treasurer, he has learned he lacks the resources to make things much better. The county doesn’t have a single drug-rehabilitation center, nor does it have the deputies needed to respond to all the drug-related complaints. (He had to lay off five of his 15 men last year.) “People are dying every week down here,” says West. “It’s a shame what’s happening.”

But what got him boiling mad was the news report that night highlighted War, an 800-person town in McDowell County. It explained how War had come to be flooded with far more prescription pain medicines than its population could ever reasonably or safely consume. The medication had been shipped there, West learned from the news, by a handful of extremely large, highly profitable companies that distribute prescription drugs across the country.

2017年《财富》500强榜单上麦克森排名第五。 

韦斯特对滥用止疼药的满腔愤懑终于找到了发泄对象:所谓的零售商。“在我看来,这些零售商跟街边毒贩没什么两样,”他告诉《财富》杂志。这位警长希望走刑事诉讼,即便做不到也要想办法让药企做出些补偿。去年12月,麦克道威尔县成为州里第一个向“三大”药品经销商提起诉讼的,三大是指今年在《财富》500强里排名第五的麦克森,年收入达1920亿美元;500强排名第11的美源伯根公司,年收入1470亿美元,还有500强排名第15的卡地纳健康集团,收入1220亿美元。三家公司都否认了指控,声称遵守了所有相关法律,而且在跟当局努力解决药物滥用问题。

不仅韦斯特将目标指向药品经销商的同时,公众对药品行业在处方药经销的关注也在增加,而且对西弗吉尼亚的乱象非常愤怒。去年《查尔斯顿邮报》记者埃里克·艾尔揭露出惊人的细节,系列报道后来荣获普利策奖,其中艾尔列出了一组令人震惊的数据,从中可见医药行业运送到西弗吉尼亚的药品数量,也是医药公司拼命想捂住的事实。

数字令人难以置信:2007年到2012年间,随着全国滥用止疼药失控,药品经销商运向西弗吉尼亚的止疼药共计7.8亿片,也即当地的男性、女性和小孩人均433剂。据《查尔斯顿邮报》分析,仅三大药企就占了一半还多,约4.23亿片。

West now had a new target for his frustration about the growing toll of opioids: the so-called wholesalers. “In my thinking, they were no different than drug dealers selling on the street,” he tells Fortune. The sheriff wanted a criminal prosecution, or failing that some compensation from those companies for the damage they’d done. In December, McDowell became the first county in the state to file a lawsuit against the “big three” drug distributors: McKesson (mck, -0.01%), No. 5 on this year’s Fortune 500, with $192 billion in revenue; AmerisourceBergen (abc, -0.38%), No. 11, with $147 billion; and Cardinal Health (cah, +0.32%), No. 15, with $122 billion. All of the companies deny the charges and say that they comply with all relevant laws and are working with authorities to prevent abuse in the system.

Sheriff West took aim at the wholesalers at a moment of growing focus on the industry’s role in prescription drug distribution and outrage about what it had done in West Virginia. Damning details emerged late last year thanks to Eric Eyre, a reporter at the Charleston Gazette-Mail. In a Pulitzer Prize–­winning series, Eyre published a staggering set of data—some of which the industry fiercely fought to keep under court seal—revealing just how many opioids the industry had delivered to the state.

The numbers are hard to fathom: Between 2007 and 2012, as the nation’s opioid epidemic spiraled out of control, wholesalers collectively shipped 780 million pain pills to West Virginia—or 433 doses for every man, woman, and child there. The big three alone delivered more than half of those, according to the Gazette-Mail’s analysis: some 423 million pills.

图片提供:尼古拉斯·拉普

其中小城市的比例奇高。西弗吉尼亚小镇吉尔伯特(人口433人)最近向药品经销商提起诉讼。起诉书中显示,2007年到2012年间药企向该地运送了533.197万剂氢可酮和氧可酮。

滥用止疼药之风在全美各处蔓延,不只是西弗吉尼亚。现在美国人死于药物滥用的几率很可能比死于车祸要高。2015年因滥用止疼药致死案为每天91例,还有很多人挣扎在生死边缘。每天都有超过1000人因滥用处方止疼药在急诊接受治疗。1999年以来止疼药销售增长几乎翻了两番。估计的数字是约有250万人在跟滥用止疼药成瘾抗争。

过去这些年里,药物上瘾的人要么接受指责,要么就是同情。随意开出处方药的医生受到严厉指责。一些生产止疼药的药企,例如奥施康定的普渡制药更是千夫所指。如今人们也开始追究药品经销商的责任。

业内巨头麦克森不可避免地被推上风口浪尖。

Small cities were disproportionately flooded. The West Virginia town of ­Gilbert (pop. 433), recently filed its own lawsuit against the distributors. In its complaint, the municipality alleged that between 2007 and 2012 it was shipped 5,331,970 doses of hydrocodone and oxycodone.

America is suffering through a full-blown opioid epidemic—and it’s hardly confined to West Virginia. It is now significantly more likely that an American will die of a drug overdose than in a car crash. In 2015 opioid overdoses claimed 91 lives a day in the U.S. Many other users hover on the edge of survival. On a typical day, more than a thousand people are treated in ERs across the country for misusing prescription opioids. Since 1999 the amount of opioids sold almost quadrupled. It’s estimated that some 2.5 million struggle with addiction to prescription opioids.

The people who have fallen under the sway of addiction have been blamed or sympathized with over the years. The doctors who casually prescribe the meds have been criticized. The companies that make the opioids, such as Purdue Pharma (the seller of OxyContin) have been lacerated. Now the distributors are being called to account.

That applies perhaps most of all to the giant of the industry: McKesson.

麦克道威尔县警长办公室。在马丁·韦斯特的努力下,麦克道威尔成为全美首个向三大药品经销商提起诉讼的地方政府,麦克森公司是被告之一。图片提供/摄影:马特·艾希
 

司法部1月宣布,因2008年到2013年间麦克森向部分地区运送大量极容易上瘾的止疼药可疑订单,却未向美国缉毒局警示,已达成1.5亿美元的和解协议。这笔罚款为有史以来金额最高,此前的12月司法部与卡地纳健康也就类似指控达成和解协议,金额为4400美元。而且麦克森此前就触犯过联邦法律。2008年麦克森因类似指控被罚1325万美元。麦克森与司法部刚刚达成的协议显示,接下来五年麦克森将严格遵守和解协议,而且要接受独立监督。(麦克森和卡地纳健康都表示将遵守相关法律,化解争议跨越分歧,与政府部门保持密切合作。)

除了麦克道威尔县的指控,麦克森还面临2016年西弗吉尼亚首席检察官帕特里克·莫瑞斯提交的诉讼。该指控称2007年至今,麦克森未能识别、汇报并阻止向西弗吉尼亚运送的止疼药可疑订单,违反了该州管制药品法。麦克森已出庭应诉。

今年1月三大药企中另外两家也与西弗吉尼亚州和解了漫长的诉讼,不过两家企业都未承认有不法行为。卡地纳健康同意支付2000万美元,并发表了以下声明:“本公司否认指控,卡地纳健康认为处方药滥用是由成瘾和需求催生的问题,要从多方面考虑。”美源伯根同意向西弗吉尼亚支付1600万美元。在西弗吉尼亚代表美源伯根的律师阿尔·艾姆什表示,“我们的工作就是打造安全可靠的系统,确保从药企合法购买药物,安全送达后合理服用。”

随着公众和政界声讨滥用药品的声浪高涨,不管是和解协议还是药品倾销的指责都导致此前低调的药品批发行业如坐针毡。不过有关药品经销商在药品供应链中的角色讨论并非第一次。事实上,过去十年里就药品监督职责,该行业与美国缉毒局一直有摩擦。

如今随着危机愈演愈烈,麦克森跟同行们也益发感觉受到误解和不公平的指责。药企认为自己是美国医疗系统中的无名英雄,默默无闻又高效可靠地将必要的药品送到需要的地方。企业总结出很多不该承受职责的理由,说到底就是“嘿,我们只是中间人而已。”

In January, the Department of Justice announced that McKesson had settled, for $150 million, civil claims that from 2008 to 2013 the company had failed to warn the DEA about the large number of suspicious orders of highly addictive painkillers it had shipped to certain parts of the country. The penalty is the largest of its kind against a wholesaler, greatly exceeding a $44 million settlement the Justice Department reached with Cardinal Health in December on similar charges. And McKesson had run afoul of the feds before. In 2008 the distributor settled similar allegations for $13.25 million. According to the terms of its recent deal with the Justice Department, McKesson will operate under a heightened compliance agreement and the watchful eye of an independent monitor for the next five years. (McKesson and Cardinal Health both say they follow relevant laws and that they resolved claims to move beyond disagreements and work more closely with the government.)

On top of the suit by McDowell County, McKesson is now facing a lawsuit brought in 2016 by West Virginia Attorney General Patrick Morrisey. That suit alleges that the distributor failed to identify, report, and stop the shipment of suspicious orders of opioids in the state from 2007 to the present in violation of West Virginia’s controlled substances act. McKesson is fighting the charges in court.

The other two members of the big three in January settled long-running lawsuits with the State of West Virginia over alleged violations, though neither admitted wrongdoing. Cardinal Health agreed to pay $20 million to the state and issued this statement: “While the company denies the state’s allegations, Cardinal Health recognizes that the epidemic of prescription drug abuse is a multifaceted problem driven by addiction and demand.” And AmerisourceBergen agreed to pay West Virginia $16 million. Says Al Emch, an attorney who represents AmerisourceBergen in West Virginia, “Our job is to create a safe, dependable system to take these drugs that we purchase from the manufacturer and deliver them securely.”

The settlements and pill-dumping allegations have put the previously low-profile wholesaling industry in the hot seat just as public and political outrage over the opioid epidemic reaches a fever pitch. But it’s hardly the first time questions over the role of distributors in the pharmaceutical supply chain have been raised. Indeed, the industry has sparred with the DEA for much of the past decade about the role it should play in monitoring the delivery of drugs.

Today, as the crisis continues to spiral, McKesson and its peers feel misunderstood and unfairly targeted. As they see it, they’re unsung heroes in the American health care system—the quiet, efficient, reliable machine that gets essential medications where they need to go. They offer elaborate reasons for why they’re not to blame, which boil down to “Hey, we’re just middlemen.”

图表显示了关于滥用止疼药危机的问卷调查结果。

当前情况下,止疼药生意无疑很难平衡。“不卖最简单,但现实是确实有人需要,”长期担任麦克森首席执行官的约翰·哈默格伦表示,他一直强调麦克森希望做正确的事。“我们之所以分发这些止疼药物,是因为很多病人对药品有合理需求,开具诊断的医生也都是专业知识丰富且出于好意,都是为了病人考虑。”

事实上,滥用止疼药危机是一场庞大的集体失败,没人真正了解危机的实质,等到了解却为时已晚。医药企业不明白,当然有时也不愿意了解止疼药可能的危害,直到滥用肆虐才察觉。医生开药病人拿药时,药剂师并未保持必要的警惕。虽然出现各种警示信号,但美国缉毒局一直在提高处方止疼药药物的限额,直到2013年才停止。也有人表示,如果缉毒局真的阻断供应情况只能更糟,上瘾的人会转向海洛因。

美国之所以止疼药蔓延,麦克森之类药品经销商确实有责任。为了进一步了解现状成因,也为了考察企业行为对某些受创最严重地区的影响,《财富》杂志深入研究了麦克森与止疼药类药物的历史纠葛。我们采访了禁毒官员、行业高管、检察官,还有在一线对抗危机的西弗吉尼亚居民。

可以明确的是,肯定不完全是麦克森的错。但离开药品经销商也不可能出现滥用蔓延。

麦克森内部有个激励人的说法特别流行。公司总部,还有经销中心入口上方都能看到:“药品不是普通的货物,每一份背后都是病人的期待。”

有了这个说法,麦克森在全美马不停蹄地运送药物仿佛也多了人情味。全公司68000名员工一周七天高效地将数百万药物送往各地。药品种类繁多,从热敏化疗药到普通的阿司匹林都包括。

大部分分发工作都在夜间进行,全公司28个经销中心晚上格外热闹。工作期间,地上堆满各式药物,仿佛小型的主题公园,红色蓝色的运输箱在复杂多层的输送轨道上蜿蜒行进。一般晚上7点工人们开始上班,处理当日订单,拣取药物放置在相应的运输箱中。整个流程都为了高效优化:麦克森对拣取处理药品每个环节上员工每个动作花的时间都做了精确计算。

某些特定的药物只有特定员工才能拣取。其中就包括管制药品,一般在上锁且密切监控的环境中完成,存放在受缉毒局监管的区域。针对类似处方止疼药之类最容易上瘾的药物,拣放都在所谓的保险库里,用专门的密封塑料袋存放,相关工作人员都经过背景调查,现场还有好几台监控。

The business of opioids undoubtedly presents a tricky balancing act. “It would certainly be simpler if we didn’t sell them anymore, but the reality is there’s a need,” says John Hammergren, McKesson’s longtime CEO, who stresses his company wants to do the right thing. “The reason we distribute these products is that there are legitimate patients that need these medicines and who are being prescribed these medicines by well-informed, well-intended doctors who are caring for these patients.”

In truth, the opioid crisis is a story of colossal, collective failure—an epidemic that no one fully understood until it was too late. The medical establishment didn’t grasp—in some cases, didn’t want to grasp—the destructive potential of the drugs it was giving out to manage pain until they began to wreak havoc. Pharmacists were not as curious as they should have been about doctors doling out prescriptions or patients filling them. Despite warning signs, the DEA consistently raised the national quotas for prescription opioids until 2013. Some argue that when the agency did choke the supply, the epidemic simply got worse, as addicts turned to heroin.

But it’s also true that the drug distributors, including McKesson, played a role in the proliferation of pain pills across America. To better understand how that came to be—and the impact of the company’s behavior on some of the country’s hardest-hit communities—­Fortune delved deeply into McKesson’s history with opioids. We interviewed drug enforcement officials, industry executives, prosecutors, and average West Virginians battling the crisis on the front lines.

One thing is clear: It certainly wasn’t all McKesson’s fault. But you can’t have a drug epidemic without a distributor.

There is a favorite motivational saying at McKesson. It’s displayed prominently in the company’s headquarters and over the entrances to the floors of its distribution centers (“DCs”): “It’s not just a package, it’s a patient.”

The slogan serves to humanize the never-ending process of moving pills across America. Seven days a week the company’s 68,000 employees work to efficiently distribute millions of essential medications. Those drugs run the gamut from temperature-sensitive chemotherapy agents to aspirin.

Most of the action actually happens at night, when the company’s 28 DCs really come alive. During those hours, the floor looks like a miniature amusement park, with red and blue tote bins zipping along an elaborate, multilevel conveyor track. Workers report at 7 p.m. to begin fulfilling the day’s orders, picking medications and depositing them into the corresponding tote. The process is optimized for efficiency: ­McKesson has planned and timed every human motion required in the picking process.

There are some drugs only certain people can pick. Those include controlled substances, which are locked, monitored, and stored in DEA-regulated spaces. The most addictive drugs, like prescription opioids, are held in a so-called vault and packaged in specially sealed plastic bags by background-checked workers under the gaze of several cameras.

麦克森28个经销中心之一。处方止疼药存储在专门的“保险库”中,工作区周围都有监控,负责处理药品的工人都要经过严格的背景调查。图片提供:麦克森公司。

麦克森大多数经销中心要服务数千家药房。送货车没有标志,总是半夜出发以确保药品早晨可送达。送货准确率高达99.996%,即绝大多数客户都能收到准确的药品。

从很多方面来看,麦克森是家低调行事的大公司。总部在旧金山市中心一座灰色高楼里,虽然大楼名字叫麦克森广场,但很可能旧金山很多眼里只有增长的科技大佬都不知道这里有一家营收近2000亿美元的大公司。(大楼附近经常会有抗议,不过一般都是冲着同在楼里办公的参议院戴安娜·范斯坦。)

低调没什么不好,但确实掩盖了麦克森悠长却辉煌的历史。

麦克森成立于184年前的纽约,当时是曼哈顿一家小药店,主要向停在港口的船只卖药。几十年之后,麦克森已在17个州出售药品,送货工具是大篷马车。很快麦克森开始生产药品、补药和酊剂,而且作为制造商的名气越来越大。禁酒令时期(1920年-1933年,译者注),掌控公司的是个私酒贩。后来公司经销商品种类繁多,从酒类到通心粉到WD-40金属保养剂都涉及,后来才将重心放在医药产品上。

Most of McKesson’s DCs serve thousands of pharmacies. The company’s unmarked delivery trucks begin rolling out at midnight to ensure the medications make it to their destination by morning. The company has a 99.996% accurate fill rate, meaning its customers almost always get exactly what they order.

McKesson is in many ways a massive corporation hiding in plain sight. The company is headquartered in a tall gray office tower in downtown San Francisco. It’s called McKesson Plaza, but chances are many of the city’s growth-obsessed tech bros don’t even know the nearly $200 billion company is there. (Periodically there are lively protests at the building, but they’re typically aimed at Sen. Dianne Feinstein, a fellow tenant.)

Its low profile suits the company just fine, but it does mask the corporation’s long and rather extraordinary history.

McKesson was founded 184 years ago in New York as a small Manhattan shop supplying drugs to ships docked in the harbor. A couple of decades later, its sales territory ranged across 17 states, which McKesson served via covered wagon. The company soon started making drugs, tonics, and tinctures, and it became better known as a manufacturer. For a time, during Prohibition, it was owned by a bootlegger. Later it distributed everything from alcohol to pasta to WD-40 before turning its focus exclusively on health care.

图片提供:麦克森公司
 

上世纪90年代末出现会计丑闻后,彼时年仅40岁的汉默格伦担任联合首席执行官。汉默格伦来自明尼苏达一座小镇,为人谦逊。2001年起正式担任首席执行官。在他领导下,公司伴随医药行业快速发展获益巨大。他任职期间,麦克森营业收入从300亿美元规模增长到近2000亿美元,在《财富》500强中排名第38。他的经营理念是逐渐渗入直接面对客户的业务,而不再只当供应链上一个环节。麦克森现在还管理癌症诊所,向医院药房提供咨询,为药品管理开发技术。

随着公司成功,汉默格伦也获得不菲的报酬,薪酬堪称天价。他一直是美国收入最高的高管之一。根据过去10年公司报表,汉默格伦总收入达6.39亿美元。

近年来药价持续上扬也对公司业绩形成提振。不过经销业务竞争也很激烈,尤其在争取独立药房方面。所谓独立药房一般都是家庭经营,利润率往往最高,而在西弗吉尼亚药品滥用方面作用十分关键。

拉吉·马辛正重复每周四的惯例:在电台讨论滥用止疼药。时间是早上刚过9:30,无线调频WELD 960,广播站位于几乎不存在的小镇菲舍尔。菲舍尔距离拉吉在彼得斯伯格的家开车约20分钟,也是西弗吉尼亚州波多马克高地上另一个小地方。这里位于州东部,狭长地带里分布着80个乡村县城,基本上人人都互相认识。当然类似拉吉·马辛的名人更是大名鼎鼎。

近来作为波多马克高地反歧视项目主管,马辛跑了不少路,主导培训项目,在镇里发表有关上瘾症的演讲。最近他在彼得斯伯格开设了第一个药物滥用诊所,每个月都要主持几十场会议。他向州官员规律汇报工作,今年还就处方药品监管研究项目获得了联邦基金。

在此之前,53岁的马辛曾是当地的医生,意外陷入止疼药上瘾后, 2010年因开过量止疼药入狱。他的案子牵涉甚广,后来因当地药房对他的处方完全放任,联邦政府对西弗吉尼亚彼得斯伯格的药房开展调查,最后还查到当地药房的供应商:麦克森。

After an accounting scandal in the late 1990s, Hammergren, a then 40-year-old of modest upbringing from small-town Minnesota, was named co-CEO. He took sole possession of the job in 2001. And under his leadership the company has been one of the biggest beneficiaries of the vastly expanding health care economy. During his tenure, McKesson has grown from a $30 billion business, ranking No. 38 on the Fortune 500, to a nearly $200 billion operation. He has done so in part by insinuating McKesson, once just a supply-chain functionary, more deeply into the business of its customers. McKesson now manages cancer clinics, consults for hospital pharmacies, and makes technology used in managing pharmacies.

Hammergren has been rewarded handsomely for this success—some might say obscenely. He has consistently been one of America’s highest-paid executives. Over the past 10 years, according to company filings, Hammergren has taken home $639 million in total compensation.

The skyrocketing price of pharmaceuticals has lifted the fortunes of the wholesalers in recent years. But the distribution business is incredibly competitive. And that’s particularly true when it comes to winning the business of independent pharmacies. These are the mom-and-pop stores off which the industry tends to make the highest margins—and which have featured prominently in the narrative of West Virginia’s opioid epidemic.

Raj Masih is doing what he does every Thursday morning: talking opioids on the radio. It’s just after 9:30 a.m., and he’s in the studio at WELD 960, an AM talk radio station in a barely there town called Fisher. It’s about a 20-minute drive from Masih’s home in Petersburg, another speck on the map in the Potomac Highlands region of West Virginia. This rural, eight-county area in the mountains of the state’s eastern panhandle is the sort of place where everyone knows your name—especially if you’re Raj Masih.

These days, as the director of the Potomac Highlands Guild’s anti-stigma program, Masih (pronounced “Ma-SEE”) clocks a lot of miles, leading trainings and speaking at town halls about addiction. He recently opened the area’s first substance abuse clinic in Petersburg, where he runs dozens of meetings per month. He periodically briefs state politicians on his work, and this year he got a federal grant to study prescription drug monitoring programs.

But before all that, Masih, 53, was the local doctor who got hooked on pain pills and, in 2010, went to prison for prescribing too many opioids. His case led to others, including the federal investigation of the Petersburg, W.Va., pharmacy that filled his many prescriptions—and ultimately of the distributor that supplied the pharmacy: McKesson.

图片提供:尼古拉斯·拉普

如今讨论的焦点是烯丙羟吗啡酮,也叫纳洛酮,一种用来治疗滥用止疼药上瘾的药物。今年2月西弗吉尼亚州医疗数据中心一项研究发现,2016年至少818人死于用药过量。这一数字比2015年增长了13%。据疾病防治中心资料,西弗吉尼亚用药过量死亡比例也高于全国平均水平,每10万人就有41.5例。(其次是新罕布什尔州,每10万人有34.3例死亡,肯塔基州为29.3例。)为了应对危机,去年西弗吉尼亚强制要求全州所有出售纳洛酮的药房只卖给持证用户,但很多药房表示拒绝。

节目主持人史蒂夫·戴维斯大声质疑,虽然纳洛酮能降低过量用药的威胁,但不会导致新的上瘾。另外他表示同情不愿出售纳洛酮的药房,因为不知道以后会不会受到指责。

马辛穿着牛仔裤和有衣领扣的衬衫,他表示药剂师的态度是导致上瘾受歧视的典型例子。“有些人会想,'上瘾是这些人自找的。让他们去死好了。为什么要帮他们走出滥用药物的泥潭?'”他说。马辛指出,持歧视态度的药房却对出售极容易上瘾的止疼药,例如氧可酮一点负罪感都没有。马辛表示,“整个社区的思维方式都应该调整。”

Today’s subject is naloxone. Also known by the brand name Narcan, it is a medication used as an antidote for opioid overdoses. An analysis in February by the West Virginia Health Statistics Center found that at least 818 people had died of drug overdoses in 2016 in the state. That was 13% more than in 2015, when West Virginia’s overdose death rate led the nation, with 41.5 cases per 100,000 people, according to the Centers for Disease Control and Prevention. (The next highest rate was in New Hampshire, with 34.3, followed by Kentucky with 29.3.) In response to the crisis, last year the West Virginia legislature mandated that all pharmacies in the state carry naloxone and dispense it to certified users, but many pharmacies were refusing to do so.

The host of the show, Steve Davis, wonders aloud whether naloxone enabled addicts, by reducing the threat of fatally overdosing, and he concedes that he’s sympathetic to pharmacists who don’t want to carry it for fear of being blamed later.

Masih, who’s wearing jeans and a white button-down, counters that the resistance by pharmacists is another example of stigmatizing addicts. “Some have an attitude, ‘These people did this to themselves. Just let them die. Why do we want to bring them back from an overdose?’” he says. The same pharmacies, he points out, have no qualms about carrying highly addictive painkillers such as oxycodone. Says Masih, “We need a change of community mindset.”

西弗吉尼亚州彼得斯伯格,马辛在鲁斯·亨德里克药品滥用资源中心。图片提供/摄影:马特·艾希
 

2000年马辛全家从得克萨斯搬到西弗吉尼亚小镇时,并未料想到后来的变故。刚搬过来时他在当地医院的急诊室工作,医院规模不大,一座砖石建筑,跟南北战争纪念馆同在一座小山上。马辛父亲是印第安医生,母亲则是英式主妇,一家人就此在只有2500人的彼得斯伯格定居。以前马辛很喜欢豪车,他有一辆保时捷,一辆悍马,还有一辆马自达敞篷车。他喜欢追求刺激的活动,例如印地赛车和用AK-47打猎。

即便偶有不满意之处,但总体来说马辛喜欢在彼得斯伯格的生活。他劝兄弟拉维也搬了过去。他还教小朋友踢足球。别人看来他是个称职且关心人的医生。

2007年,马辛的兄弟在附近的穆尔菲尔德开了一家急诊诊所兼日光浴沙龙。地址距离当地最主要的雇主都很近,包括火鸡肉厂Pilgrim’s Pride,一家美国Woodmark家具厂,而且诊所里配备了全套设备,从手术吸泵到创伤处理室一应俱全。后院甚至还有直升机停机坪。

这个美国梦距离实现只有一个问题。马辛对氢可酮上瘾了,氢可酮是一种强效止疼药,例如维柯丁Vicodin和Lortab。他上瘾是从2004年开始的,一次印地赛车中他背部受伤。他发现找不到人替第二天的急诊班氢可酮,就去医院库房吃了一剂。吃完感觉特别好,不仅身体的疼痛消失不见,工作中经常困扰的疲惫倦怠感也一扫而光。“所有烦恼烟消云散,”他说。

后来他一直偷偷吃药,剂量越来越大,也更加频繁。他也深知自己在堕落,告诉自己要节制。每天他都发誓第二天戒掉,但到了第二天总能找到理由继续吃药。有时能控制住“戒掉”,没几个小时就会感觉极其糟糕而且身体很虚弱。很快他就吃完了医院的库存,于是开始频繁给朋友和家里其他人开处方,从当地各种药房买药,开来的药当然都是自己吃了。

Masih didn’t know what to expect when he moved his family from Texas to this corner of West Virginia in 2000. He relocated there to run the emergency room in a local hospital, a small brick building that shares a hill with a Civil War memorial site. The son of an Indian surgeon and a British homemaker, Masih stuck out in Petersburg, a town of 2,500. He had a taste for flashy cars—his fleet included a Porsche, a Hummer, and a Mustang convertible—and thrill-seeking hobbies like IndyCar racing and hunting with an AK-47.

But even if he was something apart, Petersburg suited Masih. He convinced his brother Ravi to move there as well. He coached youth soccer. He earned a reputation as a good and caring doctor.

In 2007, the Masih brothers opened an urgent care clinic atop a tanning salon in neighboring Moorefield. It was strategically close to the area’s major employers—a Pilgrim’s Pride turkey plant, an American Woodmark factory—and it was outfitted with all the trappings of an ER, from surgical suction pumps to a trauma bay. There was even a helipad out back.

There was just one problem with this American dream. Masih was addicted to hydrocodone, the powerful opioid in pain medicines like Vicodin and Lortab. His addiction began in 2004, when he hurt his back in an IndyCar wreck. When he couldn’t find someone to cover his ER shift the next day, he turned to the hospital’s supply room and took a sample of the drug. He felt amazing on it—not only unburdened of his physical pain, but also of the fatigue and burnout he typically felt on the job. “Everything evaporated,” he says.

He kept taking the samples, only in higher doses and more frequently, and while he knew he was on a slippery slope, he told himself he was in control. He vowed each day that he’d quit the next. But then, inevitably, he found a reason to take the drugs again. When he did manage to “quit,” he experienced the horrible and debilitating sensations of withdrawal within a few hours. He quickly ran through the hospital’s samples and began writing prescriptions for his friends and family members—all of which he’d get filled himself at the area’s various pharmacies.

在彼得斯伯格开办的诊所里,努力摆脱上瘾的拉吉·马辛(穿白衬衫面对镜头者)参加匿名的药物成瘾互助会。图片提供/摄影:马特·艾希

秘密和耻辱感让他饱受折磨。“开车的时候都在想,‘从哪能多开一张处方?’我真的很想摆脱那种状态。”

一边深受药瘾折磨,马辛还继续行医。在氢可酮作用下,他总是感觉将医学玩弄股掌之上,精力充沛而且超级能干。开处方时他的标准也变得十分放松,经常轻易给别人开止疼药之类强效药物。他经常随意地在处方上盖上“去JUDY’S开药”。“我开处方的标准非常低,”他告诉我。“极其随意,真的。”

事情终于在2009年8月败露。一群特警闯进马辛的诊所,把他铐在椅子上,搜查了所有文件。他被关进监狱,没过几天就想自杀,受到上帝感召之后下决心戒除药瘾。法院宣判他不当开具管制药品处方的罪名成立时,他反而感觉轻松。刑期是48个月。

马辛想清楚了要从头开始,但西弗吉尼亚周北部检察院办公室并未简单放下这个案子。他们觉得这条线索背后没准能钓到大鱼。

检察院办公室位于惠灵市,一座慵懒且风景如画的小镇,就在与俄亥俄州交界的南部。很多年来这个办公室一直积极追踪滥用止疼药危机背后的黑手。但收效不大。危机仍在蔓延。

His secret and the shame of it exhausted him. “I’d be driving and thinking, ‘Where am I going to get my next script from?’ I so badly wanted to be out of it.”

Even while trapped in this cycle of addiction, Masih continued to practice medicine. Indeed, on hydrocodone, he felt at the top of his medical game, energized and hypercompetent. He also became very lax in doling out powerful narcotics like the painkillers that had him so hooked. He’d send patients away with a prescription rubber-stamped with the words FILL AT JUDY’S. “My threshold for prescribing was very low,” he tells me. “I prescribed recklessly. I did.”

It all caught up with him in August 2009, when a SWAT team burst into Masih Medical and handcuffed him to a chair while they searched his files. He was hauled to jail where in a few days’ time he says he contemplated suicide, found God, and resolved to get clean. By the time he pleaded guilty to one count of misprescribing a controlled substance, he felt free. He was sentenced to 48 months in prison.

Masih might have been ready to start over, but the U.S. Attorney’s Office in the Northern District of West Virginia hadn’t quite let go of his case. They thought it might lead to something bigger.

The office, which is based in Wheeling, a sleepy and picturesque town just south of the Ohio border, had for years been aggressive in going after the bad actors involved in the region’s opioid crisis. But it seemed to make little difference. The epidemic raged on.

西弗吉尼亚州贝克利附近的煤矿旧址。图片提供/摄影:马特·艾希
 

阿兰·麦格尼格尔是当地民事法庭助理检察官,他认为应对处方药疯狂滥用需要全盘战略,也是他经常用来处理医疗诈骗的方法:找到守门人。有些人任由马辛违法开具处方,还有些企业将越来越多药品送往西弗吉尼亚。“要阻断犯罪链条,”他说。

这项策略绝非仅在惠灵适用。本世纪初随着网络售药兴起,滥用止疼药开始蔓延,美国缉毒局就考虑过如何监管边境医药供应链。缉毒局认为药品经销商是全国医药行业的关键,要阻止止疼药滥用问题就得抓经销商。事实上,根据法律要求药品经销商本就应该提供协助。

相关法律就是已有数十年历史的管制药品法案,要求麦克森之类的批发商设立系统检测并防止出现药品销售“偏离正轨”,或是未经许可使用处方药。出现“可疑订单”经销商要向美国缉毒局汇报,包括订单规模、频次异常,或是有违正常模式。

To Alan McGonigal, an Assistant U.S. Attorney in the district’s civil division, the rampant abuse of prescription drugs required a more holistic strategy, one that he had often used in prosecuting health care fraud: Find the gatekeepers. Someone had been filling Masih’s many illegitimate scripts, and some company had been sending more and more drugs to rural West Virginia. “We had to stop the flow,” he says.

That strategy wasn’t unique to Wheeling. The DEA had begun contemplating how it regulated the broader pharmaceutical supply chain back in the mid-2000s as the online pharmacies flourished and the opioid epidemic took root. The DEA viewed distributors—the nation’s pharmaceutical fire hose—as key to its efforts to stop criminal misuse of pain pills. By law, in fact, it’s something distributors are required to help prevent.

That law is the decades-old Controlled Substances Act, which requires wholesalers like McKesson to maintain a system to detect and prevent “diversion,” or the nonsanctioned use of prescription drugs. Distributors are required to report any “suspicious orders”—those of unusual size, frequency, or deviating from normal patterns—to the DEA.

西弗吉尼亚州麦迪逊,麦克森向Larry’s免下车药房运送药品。据《查尔斯顿邮报》调查,2007年到2012年间Larry’s是州内卖止疼药最多的药房之一。图片提供/摄影:马特·艾希
 
 

但2005年之前,规定并未真正执行。前律师拉里·科特表示,经销商不会检测可疑订单,缉毒局也不会去调查。拉里曾为Brady & Quarles律师事务所工作,如今该事务所代表医药行业。药品经销商只是每月上交一份“过量购买报告”,经常是厚厚一份,有时就是简单把当月收到的所有订单列一列。

随着处方药滥用四处蔓延,缉毒局开始行动。2005年秋天,美国缉毒局流通管理办公室启动了“经销商行动”,主要为了强调批发商的法律责任,明确药品滥用问题的严重性。之后的2006年和2007年,缉毒局又单独发了三封信提醒经销商应付的责任。信中不仅指出全国面临处方药滥用蔓延的严重问题,还明确提出了期望,希望相关单位“切实了解客户”,例如采用尽职调查方式确保药房和药剂师正确行事,一旦发现可疑订单要及时汇报和加以限制。

但经销商对新规定并不十分买账。行业认为,这种调查工作超出了合理范围:药品经销商的工作就是将食品药品管理局批准的药物送到在缉毒局注册的药房,经由职业医生开处方给病人。在他们看来,让药品经销商判定某个客户或某个订单是否合法,等于让他们介入临床决策。此外,经销商对药房的管制药品使用也不会完全掌握,只知道送货情况。

还有很多人抱怨缉毒局的规定太不明确或太模糊,很多抱怨其实很有道理。2016年,缉毒局主管恰克·罗森伯格承认对批发商的处理有些“模糊”。

马辛在监狱里服刑,缉毒局正紧锣密鼓地布置执行计划。根据缉毒局的档案,马辛的滥用药物处方并非凭空发生。缉毒局认为有人协助,也有人怂恿马辛。最明确地说,马辛的同谋包括彼得斯伯格商业街上连续三代家庭经营的药店Judy’s,另外一个就是该药房主要供应商,麦克森。

这就是2012年犯罪检举人和缉毒局探员向麦格尼格尔汇报的内容。麦格尼格尔批准详查。

彼得斯伯格没几家药店。马辛大部分需要止疼的病人都会去Judy’s开药,他自己也经常早上过去取药。这种关系在麦格尼格尔看来有些可疑(另外值得怀疑的是Judy’s最近在穆尔菲尔德新开了一家店面,离马辛的诊所很近)。检察官感觉小镇上这家药店有些不对劲。

“在这种小镇上住,肯定什么事都知道,”马格尼格尔说。他身材修长,脾气温和,偶尔有些冷幽默。“要说这家药房不知道马辛做了些什么,我可不相信。”

But until 2005, these rules had never really been enforced. Distributors generally didn’t identify suspicious orders and the DEA didn’t investigate them, says Larry Cote, a former lawyer for the agency who now represents the industry at the firm Brady & Quarles. Instead, wholesalers were in the habit of submitting monthly “Excessive Purchase Reports”—thick files that sometimes included every order a wholesaler had processed during the period.

With prescription drug abuse spreading, the agency attempted a reset. In the fall of 2005, the DEA’s Office of Diversion Control launched its “Distributor Initiative,” an effort to engage with wholesalers over their legal responsibilities and the severity of the country’s diversion problem. Then, in 2006 and 2007, the DEA sent three separate letters reminding distributors of their obligations. Noting that the country faced epidemic levels of prescription drug abuse, the letters also contained more explicit expectations that registrants “know their customers”—i.e., engage in due diligence to ensure pharmacies and dispensers were aboveboard—and that they report and refrain from shipping suspicious orders.

This new guidance was not well received by the distributors. As the industry saw it, this sort of investigative work fell beyond their purview: They were in the business of moving FDA-approved drugs that had been prescribed by licensed physicians to DEA-registered pharmacies. Tasking them with determining whether or not a particular customer or order was legitimate was, in their view, asking them to meddle in medical decision-making. Plus, distributors don’t have full visibility of a pharmacy’s orders of controlled substances; they only know what they deliver.

There were plenty of other complaints that the DEA’s guidance was unclear or too vague—claims that proved to have some merit. In 2016, DEA administrator Chuck Rosenberg conceded the agency had been “opaque” in dealing with the wholesalers.

By the time Masih was in prison, the DEA had begun aggressively ramping up enforcement. And by the agency’s book, Masih’s criminal overprescribing hadn’t happened in a vacuum. He’d been aided and abetted, as they saw it, by the pharmaceutical supply chain. More specifically, his accomplices had been a third-generation mom-and-pop outlet on Main Street in Petersburg called Judy’s Drug Store—as well as the pharmacy’s primary supplier, McKesson.

That was the argument that criminal prosecutors and DEA agents made to McGonigal in May 2012. McGonigal agreed to look into it.

The Petersburg area has a few pharmacies to choose from. But most of Masih’s pain patients went to Judy’s, where he also stopped some mornings to pick up medical supplies. The relationship seemed suspicious to McGonigal (as did the fact that Judy’s had recently opened a second outlet in Moorefield close to Masih’s clinic). The prosecutor was convinced that something wasn’t right about the small-town pharmacy.

“There is nothing you don’t know about what is going on in these counties if you live there,” says McGonigal, who’s trim, mild-mannered, and occasionally reveals a dry wit. “The idea that this pharmacy didn’t know what Dr. Masih was about held no water with me.”

西弗吉尼亚州彼得斯伯格的Judy’s药房,马辛很多处方都在此开药。2014年,Judy’s因不当配药遭联邦政府指控,后支付200万美元和解。图片提供/摄影:马特·艾希
 
 

2014年12月,Judy’s因不当配药与司法部达成200万美元的民事和解协议。Judy’s未承认有不法行为,不过同意遵守更严格的汇报制度,现在仍在执行。Judy’s的一位代理律师表示药剂师都认为所有配药行为都是合法的,还指出缉毒局没有采取行动针对药剂师。

Judy’s最老一家店成立于1965年,直到今天仍在营业,是彼得斯伯格中心一座小砖房。(在穆尔菲尔德的店面已经关闭。)最近有个周五我路过药店,看到一位老年女性站在收款台后,面前是一排排列整齐的塑料袋,里面都装好了药等人来取。

处理完Judy’s之后,麦格尼格尔和团队下一个目标就是麦克森的经销中心,距离马里兰州兰都弗车程三小时的经销中西负责向Judy’s送货。

其实缉毒局调查员林德赛·马洛库早就注意到麦克森在兰都弗的经销中心。马克森在缉毒局驻华盛顿办公室工作,之前就发现麦克森的可疑订单汇报有些奇怪,因为一个都没有。从来没提过Judy’s,也没提过其他几百个送货的药房,虽然送往该地的处方止疼药数量持续攀升。对任何批发商来说,一笔可疑订单都没有也不太正常。但麦克森真这么干了,还是全国最大的药品经销商。(后来经过仔细检查记录,缉毒局发现了好些漏掉的报告。)

麦克森可疑订单报告的明显缺失让人想起之前一次调查。当时调查内容是麦克森向六个地区的小型家庭客户运送过量氢可酮和其他管制药品,客户服务对象是网络药店。麦克森并未报告相关可疑订单。2008年麦克森跟司法部达成1325万美元的和解协议,但没有承认违法行为。但当时缉毒局代理负责人米歇尔·雷昂哈特强烈指责了麦克森的行为:“麦克森公司推动了全国处方药滥用问题的爆发性增长。”

2008年的和解协议中还要求麦克森打造有效的防控系统,确保以后不再犯同样的错误。所以当年麦克森启动了管制药品监控项目(CSMP)。三层系统中,麦克森每类客户每月购买管制药品都有相应标准。如果超过标准,订单会遭屏蔽而且引发审核流程。如果导致超过标准的原因很紧急,麦克森会提供药品并且在特定情况下会提升标准;如果没有合理原因,该订单会转往当地的合规官员。如果合规官认为订单可疑,订单将转回麦克森的企业合规团队。如果该团队同样认为订单可疑,麦克森将汇报给缉毒局。

不过,马洛库审查缉毒局处理兰都弗经销中心的案例时发现,很明显麦克森的合规系统没起到作用。2011年7月,她要求麦克森提供20分左右有关可疑药房的资料。当年冬天,麦克森显然也意识到出了问题;很短时间里,麦克森兰都弗经销中心就向缉毒局提交了318份可疑订单,设计之前的月份和星期。政府则认为对于如此大规模的经销中心,可疑订单的数量太少了,而且匆忙补交显得仿佛承认有问题。

麦格尼格尔和马洛库当时都不知道,但当时全国其他地方也在进行类似调查。另一起位于科罗拉多州奥罗拉,麦克森在当地的经销中心也是2008年和解协议中提到过的。2012年3月科罗拉多经销中心有一次引起检察官的关注,当时该经销中心向缉毒局汇报了一些可疑订单,都是关于同一个药房,这也是2009年以来公司首次提交可疑订单。

不管在兰都弗还是奥罗拉,两地经销中心都发出了不少管制药品。政府报告显示,两家中心都没想过订单“可不可疑”,也没提醒缉毒局注意。

合规文件透露了很多信息。文件显示麦克森管理合规项目态度很随便。药房触及标准后,经销中心总是很容易就能通过审核流程。客户需要氢可酮的理由经常很模糊,而且毫不可信——“可以提升客流量”;“增加生意”等。他们就这样拿到了药。

In December 2014, Judy’s reached a $2 million civil settlement with the Justice Department for claims of improper dispensing. The pharmacy, which did not admit to any wrongdoing, also agreed to a stricter reporting arrangement, under which it still operates. A lawyer for Judy’s says the store’s pharmacists believed they were filling legitimate prescriptions, and points out that no DEA enforcement action was ever taken against the pharmacists.

The original Judy’s remains in business today, operating as it has since 1965, out of a brick building in the heart of Petersburg. (Its Moorefield location has closed.) On a recent Friday afternoon when I stopped in, an elderly woman stood ready at the cash register in front of a row of neatly hung plastic bags, all filled with prescription medications ready for pickup.

Having dealt with Judy’s, the next target for McGonigal and his team was the McKesson distribution center, three hours away in Landover, Md., which delivered the bulk of the pharmacy’s drugs.

The Landover facility had separately landed on the radar of a DEA investigator named Lindsey Malocu. Malocu, who worked out of the agency’s Washington Field Office, had noticed something strange about McKesson’s suspicious-order reporting in her district—there hadn’t been any. Nothing about Judy’s or any of the other hundreds of pharmacies it serviced, even as the amount of prescription opioids the company delivered to the region climbed. Zero suspicious orders would be unusual for any wholesaler. But it was especially true for McKesson, the country’s biggest drug distributor. (Upon a more careful check of its records, the DEA later found a handful of reports it had missed.)

The conspicuous absence of suspicious-order reports harked back to an earlier investigation of McKesson. That incident had involved six districts where McKesson had allegedly shipped excessive volumes of hydrocodone and other controlled substances to tiny mom-and-pop customers that filled orders for online pharmacies. Those suspicious orders had gone unreported by McKesson. The company settled those claims with the DOJ for $13.25 million in 2008 without admitting wrongdoing. But the DEA’s acting administrator at the time, Michele Leonhart, had offered a brutal condemnation of the company’s conduct: “McKesson Corporation fueled the explosive prescription drug abuse problem we have in this country.”

The 2008 settlement agreement also dictated that McKesson develop an effective system to ensure it didn’t do so in the future. So that year the company launched its Controlled Substance Monitoring Program (CSMP). Under this three-tier system, each of McKesson’s pharmacy customers were assigned monthly threshold levels for their controlled substance orders. Orders at the threshold would block the order and trigger a review process. If the reason for reaching the threshold level was compelling, McKesson would supply the drugs and in some cases raise the threshold; if not, the matter would be passed to a regional compliance officer. If that officer deemed it suspicious, the order would be kicked up to McKesson’s corporate compliance team. If they also judged it suspicious, the company would then report the order to the DEA.

When Malocu examined the DEA’s records for the Landover DC, however, it was clear to her that McKesson’s compliance system had fallen down on the job. In July 2011, she requested customer files for 20 or so suspect pharmacies that had landed on her radar. That winter, McKesson apparently realized there was a problem; in a short period of time, the Landover distribution center filed 318 suspicious orders with the DEA that covered the previous months and weeks. The government considered that number to be relatively few for a distribution center of that size and the untimely filing to be something like an admission of guilt.

McGonigal and Malocu didn’t know it at the time, but across the country, there was a similar investigation taking shape. This one involved McKesson’s Aurora, Colo., distribution center, one of the facilities that had also been at the center of the company’s 2008 settlement. The Colorado facility had drawn the attention of prosecutors again in March 2012, when it alerted the DEA to a handful of suspicious orders related to one pharmacy—the only suspicious orders the facility had reported since 2009. (For more on the Colorado investigation, read Fortune's story here.)

Both the Landover and Aurora facilities had shipped lots of controlled substances. Neither had done much to determine whether the orders were “suspicious,” according to the government, or to call the DEA’s attention to them when they were.

The compliance files were especially revealing. They showed the company’s casual approach to administering its compliance program. When pharmacies hit thresholds, they typically breezed through the review process. Customers offered vague, flimsy reasons for needing more oxycodone supply—“increase in foot traffic”; “more business”—and they’d get it.

图片提供:马特·艾希
 
 

对麦格尼格尔来说,事情很简单。“他们不够重视,”他说。“我敢肯定没人恶毒地希望大街上麻醉剂泛滥。企业有时就是太追求销售成绩,忽略了可疑订单。”

麦克森方面则表示此类指责都是莫须有,宣称公司遵守所有法律法规。此外,麦克森一位发言人还表示“在麦克森,管制药品销售从来没有跟销售人员激励直接挂过钩。”

关于麦克森的调查一直在加码。到2014年夏天,全美12个地区的检察官都在调查麦克森是否存在违反《管制药品法》的行为。

麦格尼格尔表示,据政府保守估计,近四年时间里麦克森在12个地区瞒报的可疑订单数量达数万笔。问题只剩下会罚多少。检察官认为罚金应该天价才能起到明显的警告作用,1.5亿美元应该可疑。“一犯再犯是真正的大问题,” 麦格尼格尔表示。“不仅麦克森,别家也一样。如果1300万美元罚金没让他们吸取教训,那就得给点别的处罚,是吧?只有高额罚金、停业和严格遵守规定才能根本解决问题。”

后来,麦克森重新梳理了一遍监控项目,而且据说在遵守规定方面加倍努力。

负责具体工作的是加里·博格斯,2013年加入麦克森之前曾在美国缉毒局工作四十年,在政府对麦克森启动调查期间担任监管事务高级主任。现在麦克森的管制药品监管项目已有40名工作人员,其中很多都跟博格斯一样具有监管部门背景。

此外麦克森也在技术方面投入巨大,例如完善的分析系统以识别可疑订单。在博格斯领导下,麦克森开始投入更深入也更积极的尽职调查工作,可以一系列跟麦克森客户相关的诉讼看出来,相关客户都是2013年到2014年间管制药品突然遭麦克森断供的。

和解过程也促进了麦克森跟缉毒局的合作。双方都表示如今合作比较顺畅。(过去几年里缉毒局药品滥用管控办公室与行业的协作非常深入。)

2015年,汉默格伦认为麦克森应该就止疼药滥用问题积极与监管层展开对话。有些人可能认为麦克森只是问题一部分,但汉默格伦认为鉴于麦克森在医疗系统中的领导地位,应该为解决问题贡献力量。所以去年他调派几十名员工成立工作组,起草了一份白皮书,主要在华盛顿发行。文件提出六点建议。其中包括打造全国病患安全系统,该系统基于数据,帮助药剂师和医生实时鉴别可能存在滥用药物风险的病人。

可能有些奇怪,但马辛在监狱里过得很好。监狱位于西弗吉尼亚格伦威尔,监控级别为中高级,狱中人们叫他“医生”,其他囚犯跟他讲了很多如何骗医生开出氧可酮之类处方药的故事。人们为了弄药无所不用其极,让马辛大开眼界,后来他获得美国联邦监狱局批准撰写了药物滥用如何发生的教材。(他的儿子提供了很多研究材料,他在狱中的牢友之前是海洛因贩子。两人都在书中获得了作者致谢。)2014年马辛因表现良好提前获释,当时马辛跟团队已经写出了第二本手册,内容是犯人在狱中滥用药物。

平时不做宣传防范药物上瘾工作时,马辛的时间都花在跟朋友韦德·罗哈波夫合作开设的公司上,主要产品叫“猛禽”。“猛禽”是一套系统,其中包括生物识别、电子病历,还有可录制视频的眼镜,主要用来帮助医生避免开出滥用药物的处方。如今他正向医学委员会推介“猛禽”。

马辛对依法服刑心存感激,不仅仅是因为救了他一命。他不仅戒除了药瘾,而且了如果他继续滥用药物,可能已经因病丧命。去年马辛发现罹患致命的血管瘤。(马辛的父亲曾因动脉瘤破裂导致后来一直瘫痪。)马辛主要的症状是剧烈头痛,他之前吃止疼药时从来没感觉过。2015年7月,他在西弗吉尼亚大学附属医院接受了微创手术,名叫WEB血管瘤栓塞系统。这是一种全新的手术,尚未获得食品药品监督局批准,马辛是首批接受手术的患者。

如今马辛健康且清醒,他表示“能重获机会在对抗药品滥用领域工作非常兴奋,也充满感激,今后要努力帮助更多深陷上瘾症的人们。”

再回到麦克道威尔,警长韦斯特正等着好消息。自从县里提交了对药品经销商的诉讼,西弗吉尼亚好几个县和镇,还有一些外地的机构也跟着提交了诉讼,例如奥克拉荷马州的切诺基部落。三大经销商也在忙着应诉,均表示指控没有根据。

随着公共医疗危机日益严重,议会也在询问麦克森和同行的行为是否失当。今年5月,众议院能源和商业委员会启动调查,着重查药品经销商在西弗吉尼亚的“药品倾销”行为。三大经销商都已收到质询函,要求6月8日之前答复。

韦斯特深信诉讼会收到很大成效,至少他在努力对抗药品滥用之灾。“此刻我满怀希望,也诚心祷告减轻人们的痛苦,不仅为西弗吉尼亚人,更是为美国各地的人们。”他表示。“这是一场大型瘟疫,值得严肃对待。”

本文另一版本刊登于2017年6月15日出版的《财富》杂志。(财富中文网)

译者:Pessy

审稿:夏林

For McGonigal, the matter was simple. “They didn’t care enough about the issue,” he says. “I’m sure there was no malevolent desire to flood the street with narcotics. There was just too much emphasis on sales numbers and not enough with keeping an eye on suspicious ordering.”

McKesson calls those unfounded allegations and says the company complies with laws and regulations. Furthermore, a spokesman says that “at no point has there ever been a direct correlation between the sale of controlled substances and incentive compensation for McKesson sales personnel.”

The investigations of McKesson were multiplying. By the summer of 2014, prosecutors in 12 districts around the country were looking into possible violations of the Controlled Substances Act at McKesson distribution centers.

According to McGonigal, the government’s conservative estimate is that over a roughly four-year period McKesson had failed to report tens of thousands of suspicious orders in those districts. The question was how big the penalty should be. Prosecutors thought a large penalty was needed to send a message, and the $150 million figure accomplished that. “Recidivism was a real problem,” says McGonigal. “Not only with them but with others. If they’re not going to learn from a $13 million settlement, they have to learn from something, right? Dollars and suspensions and heightened compliance arrangements are the only way it’s going to get done.”

In the aftermath, McKesson has once again overhauled its monitoring programs. And by all accounts the company is redoubling its efforts on compliance.

Leading the effort has been Gary Boggs, who spent four decades as a DEA agent before joining McKesson in 2013 as the senior director of regulatory affairs, in the midst of the government’s investigations into McKesson. There are now some 40 individuals dedicated to McKesson’s controlled substance monitoring program, and many of them, like Boggs, came from an enforcement background.

The company has made significant investments in technology, such as more sophisticated analytics systems to identify suspicious orders. Under Boggs’ leadership, it has started doing deeper, more rigorous due diligence—a change that can be traced through a trail of lawsuits involving McKesson customers who suddenly had their controlled substances cut off in 2013 and 2014.

The settlement process has had a way of bringing McKesson and the DEA together. Both sides say they’re working together productively now. (DEA Diversion Control has also made a concerted effort to engage far more with the industry in the past few years.)

In 2015, Hammergren decided that it was time for McKesson to wade into broader policy conversations about the opioid epidemic. While some may see McKesson as part of the problem, Hammergren believes that his company, given its position in the health care system, might have insights to help with the solution. So last year he formed a task force of several dozen employees, and developed a white paper that McKesson is now circulating in Washington. The document offers six recommendations. Among them: the development of a National Patient Safety System, a data-driven, real-time tool to help pharmacists and physicians to identify patients most at risk of misusing medications.

Odd as it may seem, Masih thrived in prison. At the medium-high security facility in Glenville, W.Va., he quickly became known as “Doc,” and his fellow inmates regaled him with stories of how they’d once scammed physicians into prescribing them oxycodone and other narcotics. Masih was blown away by the variety and ingenuity of their methods, and he obtained permission from the Federal Bureau of Prisons to write a textbook on how drug diversion happens. (His son, who sent him research, and his cell mate, a onetime heroin dealer, both earned author credits.) By the time Masih was released in 2014—early, for good behavior—the team had written a second manual on how prisoners abuse drugs in prison.

When he’s not doing his addiction work, Masih devotes time to a company he started with his friend Wade Rohrbaugh to develop a product he calls “Raptor.” The system, which involves biometrics, electronic health records, and video-recording eyeglasses, is designed to help physicians prevent prescription drug diversion. Right now he’s shopping Raptor to medical boards.

Masih thanks his brush with the law for saving his life—in more ways than one. Not only did he kick opioids, but he was also able to manage a personal health crisis that might have killed him if he’d been using. Last year, Masih learned he had a life-threatening aneurysm. (His father had suffered a ruptured aneurysm and was disabled for the rest of his life.) Masih’s primary symptom was terrible headaches, which he says he never felt when he was on pain meds. In July 2015, he was one of the first patients to undergo a radical, not-yet-FDA-approved, minimally invasive surgical procedure at the West Virginia University hospital with a device called a WEB Aneurysm Embolization System.

Healthy and sober, Masih says he’s “thrilled and grateful to be given a second chance to work in this field helping many people suffering from the disease of addiction.”

Back in McDowell County, Sheriff West is waiting for some good news. Since the county filed suit against the distributors, a number of counties and towns in West Virginia—and a few entities beyond, such as the Cherokee Nation, in Oklahoma—have followed with their own lawsuits. The big three are fighting those, too, and dispute the merits of the claims.

Questions are also being asked about the practices of McKesson and its peers by Congress, where the dire public health crisis is increasingly top of mind. In May, the House Energy and Commerce Committee launched an investigation into the wholesaler industry’s “pill dumping” practices in West Virginia. The big three each received letters of inquiry, which they were required to answer by June 8.

West isn’t sure the lawsuits will accomplish much, but at least he tried something to counter the opioid scourge. “I’m hoping and praying we can alleviate some of the suffering, not only in West Virginia, but everywhere across the nation just about now,” he says. “It’s a major epidemic, and it’s got to be treated that way.”

A version of this article appears in the June 15, 2017 issue of Fortune.

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