在美國(guó)西弗吉尼亞，飽受藥品濫用打擊的社區(qū)將麥克森告上法庭。

去年秋天一個(gè)晚上，西弗吉尼亞麥克道威爾縣本地新聞提到濫用止疼藥危機(jī)日益嚴(yán)重，電視前的警長(zhǎng)兼會(huì)計(jì)馬丁·韋斯特終于忍無(wú)可忍。新聞里提到的內(nèi)容讓他感到極為憤怒。

62歲的韋斯特同時(shí)擔(dān)任縣里的牧師，因而目睹過(guò)很多慘劇。他在麥克道威爾縣出生成長(zhǎng)，活了一輩子卻只能眼睜睜看著家鄉(xiāng)不斷衰退。韋斯特年輕時(shí)，麥克道威爾縣還是個(gè)繁榮的小地方，位于西弗吉尼亞最南端卻是整個(gè)州的產(chǎn)煤中心。1982年之前韋斯特一直在煤礦工作，之后下了崗。29歲時(shí)他當(dāng)選縣治安法官，一當(dāng)就是27年，后來(lái)當(dāng)選為警長(zhǎng)。他負(fù)責(zé)過(guò)很多案件，發(fā)現(xiàn)越來(lái)越多當(dāng)?shù)厝艘驗(yàn)E用藥物而一蹶不振而且陷入赤貧，濫用止疼藥之風(fēng)逐漸蔓延。

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.

過(guò)去十五年間，麥克道威爾縣因?yàn)E用處方止疼藥死亡的人數(shù)越來(lái)越多，在美國(guó)所有縣排名第二（僅次于旁邊的懷俄明縣）。韋斯特認(rèn)識(shí)的很多正常人都卷入其中。有些人因?yàn)槭I(yè)開(kāi)始嗑藥，有些人因?yàn)槭軅灾固鬯幧习a。他認(rèn)識(shí)有些一家人全因?yàn)E用藥物死亡。身為牧師，他安葬了不少受害者。作為警長(zhǎng)，他也抓了不少人。作為會(huì)計(jì)，他發(fā)現(xiàn)根本沒(méi)有資源改變現(xiàn)狀?？h里一個(gè)戒除藥癮的康復(fù)中心都沒(méi)有，也沒(méi)有足夠人手處理所有與藥物相關(guān)的投訴。（去年他手下的15個(gè)人解雇了5個(gè)。）“每個(gè)星期都有人死亡，”韋斯特說(shuō)。“讓人非常遺憾?！?

但最讓他憤怒的就是那晚新聞中提到小鎮(zhèn)沃爾，麥克道威爾縣底下一個(gè)只有800人的小鎮(zhèn)。新聞里解釋了為何沃爾會(huì)出現(xiàn)大量處方止疼藥，數(shù)量遠(yuǎn)超當(dāng)?shù)厝撕侠戆踩氖褂盟健＞S斯特得知，止疼藥是由幾家規(guī)模巨大盈利極高，負(fù)責(zé)在全國(guó)銷售處方藥的大公司送到沃爾的。

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.

韋斯特對(duì)濫用止疼藥的滿腔憤懣終于找到了發(fā)泄對(duì)象：所謂的零售商?！霸谖铱磥?lái)，這些零售商跟街邊毒販沒(méi)什么兩樣，”他告訴《財(cái)富》雜志。這位警長(zhǎng)希望走刑事訴訟，即便做不到也要想辦法讓藥企做出些補(bǔ)償。去年12月，麥克道威爾縣成為州里第一個(gè)向“三大”藥品經(jīng)銷商提起訴訟的，三大是指今年在《財(cái)富》500強(qiáng)里排名第五的麥克森，年收入達(dá)1920億美元；500強(qiáng)排名第11的美源伯根公司，年收入1470億美元，還有500強(qiáng)排名第15的卡地納健康集團(tuán)，收入1220億美元。三家公司都否認(rèn)了指控，聲稱遵守了所有相關(guān)法律，而且在跟當(dāng)局努力解決藥物濫用問(wèn)題。

不僅韋斯特將目標(biāo)指向藥品經(jīng)銷商的同時(shí)，公眾對(duì)藥品行業(yè)在處方藥經(jīng)銷的關(guān)注也在增加，而且對(duì)西弗吉尼亞的亂象非常憤怒。去年《查爾斯頓郵報(bào)》記者埃里克·艾爾揭露出驚人的細(xì)節(jié)，系列報(bào)道后來(lái)榮獲普利策獎(jiǎng)，其中艾爾列出了一組令人震驚的數(shù)據(jù)，從中可見(jiàn)醫(yī)藥行業(yè)運(yùn)送到西弗吉尼亞的藥品數(shù)量，也是醫(yī)藥公司拼命想捂住的事實(shí)。

數(shù)字令人難以置信：2007年到2012年間，隨著全國(guó)濫用止疼藥失控，藥品經(jīng)銷商運(yùn)向西弗吉尼亞的止疼藥共計(jì)7.8億片，也即當(dāng)?shù)氐哪行?、女性和小孩人?33劑。據(jù)《查爾斯頓郵報(bào)》分析，僅三大藥企就占了一半還多，約4.23億片。

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.

其中小城市的比例奇高。西弗吉尼亞小鎮(zhèn)吉爾伯特（人口433人）最近向藥品經(jīng)銷商提起訴訟。起訴書中顯示，2007年到2012年間藥企向該地運(yùn)送了533.197萬(wàn)劑氫可酮和氧可酮。

濫用止疼藥之風(fēng)在全美各處蔓延，不只是西弗吉尼亞?，F(xiàn)在美國(guó)人死于藥物濫用的幾率很可能比死于車禍要高。2015年因?yàn)E用止疼藥致死案為每天91例，還有很多人掙扎在生死邊緣。每天都有超過(guò)1000人因?yàn)E用處方止疼藥在急診接受治療。1999年以來(lái)止疼藥銷售增長(zhǎng)幾乎翻了兩番。估計(jì)的數(shù)字是約有250萬(wàn)人在跟濫用止疼藥成癮抗?fàn)帯?

過(guò)去這些年里，藥物上癮的人要么接受指責(zé)，要么就是同情。隨意開(kāi)出處方藥的醫(yī)生受到嚴(yán)厲指責(zé)。一些生產(chǎn)止疼藥的藥企，例如奧施康定的普渡制藥更是千夫所指。如今人們也開(kāi)始追究藥品經(jīng)銷商的責(zé)任。

業(yè)內(nèi)巨頭麥克森不可避免地被推上風(fēng)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.

司法部1月宣布，因2008年到2013年間麥克森向部分地區(qū)運(yùn)送大量極容易上癮的止疼藥可疑訂單，卻未向美國(guó)緝毒局警示，已達(dá)成1.5億美元的和解協(xié)議。這筆罰款為有史以來(lái)金額最高，此前的12月司法部與卡地納健康也就類似指控達(dá)成和解協(xié)議，金額為4400美元。而且麥克森此前就觸犯過(guò)聯(lián)邦法律。2008年麥克森因類似指控被罰1325萬(wàn)美元。麥克森與司法部剛剛達(dá)成的協(xié)議顯示，接下來(lái)五年麥克森將嚴(yán)格遵守和解協(xié)議，而且要接受獨(dú)立監(jiān)督。（麥克森和卡地納健康都表示將遵守相關(guān)法律，化解爭(zhēng)議跨越分歧，與政府部門保持密切合作。）

除了麥克道威爾縣的指控，麥克森還面臨2016年西弗吉尼亞首席檢察官帕特里克·莫瑞斯提交的訴訟。該指控稱2007年至今，麥克森未能識(shí)別、匯報(bào)并阻止向西弗吉尼亞運(yùn)送的止疼藥可疑訂單，違反了該州管制藥品法。麥克森已出庭應(yīng)訴。

今年1月三大藥企中另外兩家也與西弗吉尼亞州和解了漫長(zhǎng)的訴訟，不過(guò)兩家企業(yè)都未承認(rèn)有不法行為?？ǖ丶{健康同意支付2000萬(wàn)美元，并發(fā)表了以下聲明：“本公司否認(rèn)指控，卡地納健康認(rèn)為處方藥濫用是由成癮和需求催生的問(wèn)題，要從多方面考慮?！泵涝床庀蛭鞲ゼ醽喼Ц?600萬(wàn)美元。在西弗吉尼亞代表美源伯根的律師阿爾·艾姆什表示，“我們的工作就是打造安全可靠的系統(tǒng)，確保從藥企合法購(gòu)買藥物，安全送達(dá)后合理服用?！?

隨著公眾和政界聲討濫用藥品的聲浪高漲，不管是和解協(xié)議還是藥品傾銷的指責(zé)都導(dǎo)致此前低調(diào)的藥品批發(fā)行業(yè)如坐針氈。不過(guò)有關(guān)藥品經(jīng)銷商在藥品供應(yīng)鏈中的角色討論并非第一次。事實(shí)上，過(guò)去十年里就藥品監(jiān)督職責(zé)，該行業(yè)與美國(guó)緝毒局一直有摩擦。

如今隨著危機(jī)愈演愈烈，麥克森跟同行們也益發(fā)感覺(jué)受到誤解和不公平的指責(zé)。藥企認(rèn)為自己是美國(guó)醫(yī)療系統(tǒng)中的無(wú)名英雄，默默無(wú)聞?dòng)指咝Э煽康貙⒈匾乃幤匪偷叫枰牡胤?。企業(yè)總結(jié)出很多不該承受職責(zé)的理由，說(shuō)到底就是“嘿，我們只是中間人而已?！?

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.”

當(dāng)前情況下，止疼藥生意無(wú)疑很難平衡。“不賣最簡(jiǎn)單，但現(xiàn)實(shí)是確實(shí)有人需要，”長(zhǎng)期擔(dān)任麥克森首席執(zhí)行官的約翰·哈默格倫表示，他一直強(qiáng)調(diào)麥克森希望做正確的事?！拔覀冎苑职l(fā)這些止疼藥物，是因?yàn)楹芏嗖∪藢?duì)藥品有合理需求，開(kāi)具診斷的醫(yī)生也都是專業(yè)知識(shí)豐富且出于好意，都是為了病人考慮。”

事實(shí)上，濫用止疼藥危機(jī)是一場(chǎng)龐大的集體失敗，沒(méi)人真正了解危機(jī)的實(shí)質(zhì)，等到了解卻為時(shí)已晚。醫(yī)藥企業(yè)不明白，當(dāng)然有時(shí)也不愿意了解止疼藥可能的危害，直到濫用肆虐才察覺(jué)。醫(yī)生開(kāi)藥病人拿藥時(shí)，藥劑師并未保持必要的警惕。雖然出現(xiàn)各種警示信號(hào)，但美國(guó)緝毒局一直在提高處方止疼藥藥物的限額，直到2013年才停止。也有人表示，如果緝毒局真的阻斷供應(yīng)情況只能更糟，上癮的人會(huì)轉(zhuǎn)向海洛因。

美國(guó)之所以止疼藥蔓延，麥克森之類藥品經(jīng)銷商確實(shí)有責(zé)任。為了進(jìn)一步了解現(xiàn)狀成因，也為了考察企業(yè)行為對(duì)某些受創(chuàng)最嚴(yán)重地區(qū)的影響，《財(cái)富》雜志深入研究了麥克森與止疼藥類藥物的歷史糾葛。我們采訪了禁毒官員、行業(yè)高管、檢察官，還有在一線對(duì)抗危機(jī)的西弗吉尼亞居民。

可以明確的是，肯定不完全是麥克森的錯(cuò)。但離開(kāi)藥品經(jīng)銷商也不可能出現(xiàn)濫用蔓延。

麥克森內(nèi)部有個(gè)激勵(lì)人的說(shuō)法特別流行。公司總部，還有經(jīng)銷中心入口上方都能看到：“藥品不是普通的貨物，每一份背后都是病人的期待?！?

有了這個(gè)說(shuō)法，麥克森在全美馬不停蹄地運(yùn)送藥物仿佛也多了人情味。全公司68000名員工一周七天高效地將數(shù)百萬(wàn)藥物送往各地。藥品種類繁多，從熱敏化療藥到普通的阿司匹林都包括。

大部分分發(fā)工作都在夜間進(jìn)行，全公司28個(gè)經(jīng)銷中心晚上格外熱鬧。工作期間，地上堆滿各式藥物，仿佛小型的主題公園，紅色藍(lán)色的運(yùn)輸箱在復(fù)雜多層的輸送軌道上蜿蜒行進(jìn)。一般晚上7點(diǎn)工人們開(kāi)始上班，處理當(dāng)日訂單，揀取藥物放置在相應(yīng)的運(yùn)輸箱中。整個(gè)流程都為了高效優(yōu)化：麥克森對(duì)揀取處理藥品每個(gè)環(huán)節(jié)上員工每個(gè)動(dòng)作花的時(shí)間都做了精確計(jì)算。

某些特定的藥物只有特定員工才能揀取。其中就包括管制藥品，一般在上鎖且密切監(jiān)控的環(huán)境中完成，存放在受緝毒局監(jiān)管的區(qū)域。針對(duì)類似處方止疼藥之類最容易上癮的藥物，揀放都在所謂的保險(xiǎn)庫(kù)里，用專門的密封塑料袋存放，相關(guān)工作人員都經(jīng)過(guò)背景調(diào)查，現(xiàn)場(chǎng)還有好幾臺(tái)監(jiān)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.

麥克森大多數(shù)經(jīng)銷中心要服務(wù)數(shù)千家藥房。送貨車沒(méi)有標(biāo)志，總是半夜出發(fā)以確保藥品早晨可送達(dá)。送貨準(zhǔn)確率高達(dá)99.996%，即絕大多數(shù)客戶都能收到準(zhǔn)確的藥品。

從很多方面來(lái)看，麥克森是家低調(diào)行事的大公司?？偛吭谂f金山市中心一座灰色高樓里，雖然大樓名字叫麥克森廣場(chǎng)，但很可能舊金山很多眼里只有增長(zhǎng)的科技大佬都不知道這里有一家營(yíng)收近2000億美元的大公司。（大樓附近經(jīng)常會(huì)有抗議，不過(guò)一般都是沖著同在樓里辦公的參議院戴安娜·范斯坦。）

低調(diào)沒(méi)什么不好，但確實(shí)掩蓋了麥克森悠長(zhǎng)卻輝煌的歷史。

麥克森成立于184年前的紐約，當(dāng)時(shí)是曼哈頓一家小藥店，主要向停在港口的船只賣藥。幾十年之后，麥克森已在17個(gè)州出售藥品，送貨工具是大篷馬車。很快麥克森開(kāi)始生產(chǎn)藥品、補(bǔ)藥和酊劑，而且作為制造商的名氣越來(lái)越大。禁酒令時(shí)期（1920年-1933年，譯者注），掌控公司的是個(gè)私酒販。后來(lái)公司經(jīng)銷商品種類繁多，從酒類到通心粉到WD-40金屬保養(yǎng)劑都涉及，后來(lái)才將重心放在醫(yī)藥產(chǎn)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.

上世紀(jì)90年代末出現(xiàn)會(huì)計(jì)丑聞后，彼時(shí)年僅40歲的漢默格倫擔(dān)任聯(lián)合首席執(zhí)行官。漢默格倫來(lái)自明尼蘇達(dá)一座小鎮(zhèn)，為人謙遜。2001年起正式擔(dān)任首席執(zhí)行官。在他領(lǐng)導(dǎo)下，公司伴隨醫(yī)藥行業(yè)快速發(fā)展獲益巨大。他任職期間，麥克森營(yíng)業(yè)收入從300億美元規(guī)模增長(zhǎng)到近2000億美元，在《財(cái)富》500強(qiáng)中排名第38。他的經(jīng)營(yíng)理念是逐漸滲入直接面對(duì)客戶的業(yè)務(wù)，而不再只當(dāng)供應(yīng)鏈上一個(gè)環(huán)節(jié)。麥克森現(xiàn)在還管理癌癥診所，向醫(yī)院藥房提供咨詢，為藥品管理開(kāi)發(fā)技術(shù)。

隨著公司成功，漢默格倫也獲得不菲的報(bào)酬，薪酬堪稱天價(jià)。他一直是美國(guó)收入最高的高管之一。根據(jù)過(guò)去10年公司報(bào)表，漢默格倫總收入達(dá)6.39億美元。

近年來(lái)藥價(jià)持續(xù)上揚(yáng)也對(duì)公司業(yè)績(jī)形成提振。不過(guò)經(jīng)銷業(yè)務(wù)競(jìng)爭(zhēng)也很激烈，尤其在爭(zhēng)取獨(dú)立藥房方面。所謂獨(dú)立藥房一般都是家庭經(jīng)營(yíng)，利潤(rùn)率往往最高，而在西弗吉尼亞藥品濫用方面作用十分關(guān)鍵。

拉吉·馬辛正重復(fù)每周四的慣例：在電臺(tái)討論濫用止疼藥。時(shí)間是早上剛過(guò)9:30，無(wú)線調(diào)頻WELD 960，廣播站位于幾乎不存在的小鎮(zhèn)菲舍爾。菲舍爾距離拉吉在彼得斯伯格的家開(kāi)車約20分鐘，也是西弗吉尼亞州波多馬克高地上另一個(gè)小地方。這里位于州東部，狹長(zhǎng)地帶里分布著80個(gè)鄉(xiāng)村縣城，基本上人人都互相認(rèn)識(shí)。當(dāng)然類似拉吉·馬辛的名人更是大名鼎鼎。

近來(lái)作為波多馬克高地反歧視項(xiàng)目主管，馬辛跑了不少路，主導(dǎo)培訓(xùn)項(xiàng)目，在鎮(zhèn)里發(fā)表有關(guān)上癮癥的演講。最近他在彼得斯伯格開(kāi)設(shè)了第一個(gè)藥物濫用診所，每個(gè)月都要主持幾十場(chǎng)會(huì)議。他向州官員規(guī)律匯報(bào)工作，今年還就處方藥品監(jiān)管研究項(xiàng)目獲得了聯(lián)邦基金。

在此之前，53歲的馬辛曾是當(dāng)?shù)氐尼t(yī)生，意外陷入止疼藥上癮后， 2010年因開(kāi)過(guò)量止疼藥入獄。他的案子牽涉甚廣，后來(lái)因當(dāng)?shù)厮幏繉?duì)他的處方完全放任，聯(lián)邦政府對(duì)西弗吉尼亞彼得斯伯格的藥房開(kāi)展調(diào)查，最后還查到當(dāng)?shù)厮幏康墓?yīng)商：麥克森。

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.

如今討論的焦點(diǎn)是烯丙羥嗎啡酮，也叫納洛酮，一種用來(lái)治療濫用止疼藥上癮的藥物。今年2月西弗吉尼亞州醫(yī)療數(shù)據(jù)中心一項(xiàng)研究發(fā)現(xiàn)，2016年至少818人死于用藥過(guò)量。這一數(shù)字比2015年增長(zhǎng)了13%。據(jù)疾病防治中心資料，西弗吉尼亞用藥過(guò)量死亡比例也高于全國(guó)平均水平，每10萬(wàn)人就有41.5例。（其次是新罕布什爾州，每10萬(wàn)人有34.3例死亡，肯塔基州為29.3例。）為了應(yīng)對(duì)危機(jī)，去年西弗吉尼亞強(qiáng)制要求全州所有出售納洛酮的藥房只賣給持證用戶，但很多藥房表示拒絕。

節(jié)目主持人史蒂夫·戴維斯大聲質(zhì)疑，雖然納洛酮能降低過(guò)量用藥的威脅，但不會(huì)導(dǎo)致新的上癮。另外他表示同情不愿出售納洛酮的藥房，因?yàn)椴恢酪院髸?huì)不會(huì)受到指責(zé)。

馬辛穿著牛仔褲和有衣領(lǐng)扣的襯衫，他表示藥劑師的態(tài)度是導(dǎo)致上癮受歧視的典型例子?！坝行┤藭?huì)想，'上癮是這些人自找的。讓他們?nèi)ニ篮昧?。為什么要幫他們走出濫用藥物的泥潭？'”他說(shuō)。馬辛指出，持歧視態(tài)度的藥房卻對(duì)出售極容易上癮的止疼藥，例如氧可酮一點(diǎn)負(fù)罪感都沒(méi)有。馬辛表示，“整個(gè)社區(qū)的思維方式都應(yīng)該調(diào)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.”

2000年馬辛全家從得克薩斯搬到西弗吉尼亞小鎮(zhèn)時(shí)，并未料想到后來(lái)的變故。剛搬過(guò)來(lái)時(shí)他在當(dāng)?shù)蒯t(yī)院的急診室工作，醫(yī)院規(guī)模不大，一座磚石建筑，跟南北戰(zhàn)爭(zhēng)紀(jì)念館同在一座小山上。馬辛父親是印第安醫(yī)生，母親則是英式主婦，一家人就此在只有2500人的彼得斯伯格定居。以前馬辛很喜歡豪車，他有一輛保時(shí)捷，一輛悍馬，還有一輛馬自達(dá)敞篷車。他喜歡追求刺激的活動(dòng)，例如印地賽車和用AK-47打獵。

即便偶有不滿意之處，但總體來(lái)說(shuō)馬辛喜歡在彼得斯伯格的生活。他勸兄弟拉維也搬了過(guò)去。他還教小朋友踢足球。別人看來(lái)他是個(gè)稱職且關(guān)心人的醫(yī)生。

2007年，馬辛的兄弟在附近的穆?tīng)柗茽柕麻_(kāi)了一家急診診所兼日光浴沙龍。地址距離當(dāng)?shù)刈钪饕墓椭鞫己芙?，包括火雞肉廠Pilgrim’s Pride，一家美國(guó)Woodmark家具廠，而且診所里配備了全套設(shè)備，從手術(shù)吸泵到創(chuàng)傷處理室一應(yīng)俱全。后院甚至還有直升機(jī)停機(jī)坪。

這個(gè)美國(guó)夢(mèng)距離實(shí)現(xiàn)只有一個(gè)問(wèn)題。馬辛對(duì)氫可酮上癮了，氫可酮是一種強(qiáng)效止疼藥，例如維柯丁Vicodin和Lortab。他上癮是從2004年開(kāi)始的，一次印地賽車中他背部受傷。他發(fā)現(xiàn)找不到人替第二天的急診班氫可酮，就去醫(yī)院庫(kù)房吃了一劑。吃完感覺(jué)特別好，不僅身體的疼痛消失不見(jiàn)，工作中經(jīng)常困擾的疲憊倦怠感也一掃而光?！八袩罒熛粕?，”他說(shuō)。

后來(lái)他一直偷偷吃藥，劑量越來(lái)越大，也更加頻繁。他也深知自己在墮落，告訴自己要節(jié)制。每天他都發(fā)誓第二天戒掉，但到了第二天總能找到理由繼續(xù)吃藥。有時(shí)能控制住“戒掉”，沒(méi)幾個(gè)小時(shí)就會(huì)感覺(jué)極其糟糕而且身體很虛弱。很快他就吃完了醫(yī)院的庫(kù)存，于是開(kāi)始頻繁給朋友和家里其他人開(kāi)處方，從當(dāng)?shù)馗鞣N藥房買藥，開(kāi)來(lái)的藥當(dāng)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.

秘密和恥辱感讓他飽受折磨?！伴_(kāi)車的時(shí)候都在想，‘從哪能多開(kāi)一張?zhí)幏?？’我真的很想擺脫那種狀態(tài)。”

一邊深受藥癮折磨，馬辛還繼續(xù)行醫(yī)。在氫可酮作用下，他總是感覺(jué)將醫(yī)學(xué)玩弄股掌之上，精力充沛而且超級(jí)能干。開(kāi)處方時(shí)他的標(biāo)準(zhǔn)也變得十分放松，經(jīng)常輕易給別人開(kāi)止疼藥之類強(qiáng)效藥物。他經(jīng)常隨意地在處方上蓋上“去JUDY’S開(kāi)藥”?！拔议_(kāi)處方的標(biāo)準(zhǔn)非常低，”他告訴我。“極其隨意，真的?！?

事情終于在2009年8月敗露。一群特警闖進(jìn)馬辛的診所，把他銬在椅子上，搜查了所有文件。他被關(guān)進(jìn)監(jiān)獄，沒(méi)過(guò)幾天就想自殺，受到上帝感召之后下決心戒除藥癮。法院宣判他不當(dāng)開(kāi)具管制藥品處方的罪名成立時(shí)，他反而感覺(jué)輕松。刑期是48個(gè)月。

馬辛想清楚了要從頭開(kāi)始，但西弗吉尼亞周北部檢察院辦公室并未簡(jiǎn)單放下這個(gè)案子。他們覺(jué)得這條線索背后沒(méi)準(zhǔn)能釣到大魚。

檢察院辦公室位于惠靈市，一座慵懶且風(fēng)景如畫的小鎮(zhèn)，就在與俄亥俄州交界的南部。很多年來(lái)這個(gè)辦公室一直積極追蹤濫用止疼藥危機(jī)背后的黑手。但收效不大。危機(jī)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.

阿蘭·麥格尼格爾是當(dāng)?shù)孛袷路ㄍブ頇z察官，他認(rèn)為應(yīng)對(duì)處方藥瘋狂濫用需要全盤戰(zhàn)略，也是他經(jīng)常用來(lái)處理醫(yī)療詐騙的方法：找到守門人。有些人任由馬辛違法開(kāi)具處方，還有些企業(yè)將越來(lái)越多藥品送往西弗吉尼亞?！耙钄喾缸镦湕l，”他說(shuō)。

這項(xiàng)策略絕非僅在惠靈適用。本世紀(jì)初隨著網(wǎng)絡(luò)售藥興起，濫用止疼藥開(kāi)始蔓延，美國(guó)緝毒局就考慮過(guò)如何監(jiān)管邊境醫(yī)藥供應(yīng)鏈。緝毒局認(rèn)為藥品經(jīng)銷商是全國(guó)醫(yī)藥行業(yè)的關(guān)鍵，要阻止止疼藥濫用問(wèn)題就得抓經(jīng)銷商。事實(shí)上，根據(jù)法律要求藥品經(jīng)銷商本就應(yīng)該提供協(xié)助。

相關(guān)法律就是已有數(shù)十年歷史的管制藥品法案，要求麥克森之類的批發(fā)商設(shè)立系統(tǒng)檢測(cè)并防止出現(xiàn)藥品銷售“偏離正軌”，或是未經(jīng)許可使用處方藥。出現(xiàn)“可疑訂單”經(jīng)銷商要向美國(guó)緝毒局匯報(bào)，包括訂單規(guī)模、頻次異常，或是有違正常模式。

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.

但2005年之前，規(guī)定并未真正執(zhí)行。前律師拉里·科特表示，經(jīng)銷商不會(huì)檢測(cè)可疑訂單，緝毒局也不會(huì)去調(diào)查。拉里曾為Brady & Quarles律師事務(wù)所工作，如今該事務(wù)所代表醫(yī)藥行業(yè)。藥品經(jīng)銷商只是每月上交一份“過(guò)量購(gòu)買報(bào)告”，經(jīng)常是厚厚一份，有時(shí)就是簡(jiǎn)單把當(dāng)月收到的所有訂單列一列。

隨著處方藥濫用四處蔓延，緝毒局開(kāi)始行動(dòng)。2005年秋天，美國(guó)緝毒局流通管理辦公室啟動(dòng)了“經(jīng)銷商行動(dòng)”，主要為了強(qiáng)調(diào)批發(fā)商的法律責(zé)任，明確藥品濫用問(wèn)題的嚴(yán)重性。之后的2006年和2007年，緝毒局又單獨(dú)發(fā)了三封信提醒經(jīng)銷商應(yīng)付的責(zé)任。信中不僅指出全國(guó)面臨處方藥濫用蔓延的嚴(yán)重問(wèn)題，還明確提出了期望，希望相關(guān)單位“切實(shí)了解客戶”，例如采用盡職調(diào)查方式確保藥房和藥劑師正確行事，一旦發(fā)現(xiàn)可疑訂單要及時(shí)匯報(bào)和加以限制。

但經(jīng)銷商對(duì)新規(guī)定并不十分買賬。行業(yè)認(rèn)為，這種調(diào)查工作超出了合理范圍：藥品經(jīng)銷商的工作就是將食品藥品管理局批準(zhǔn)的藥物送到在緝毒局注冊(cè)的藥房，經(jīng)由職業(yè)醫(yī)生開(kāi)處方給病人。在他們看來(lái)，讓藥品經(jīng)銷商判定某個(gè)客戶或某個(gè)訂單是否合法，等于讓他們介入臨床決策。此外，經(jīng)銷商對(duì)藥房的管制藥品使用也不會(huì)完全掌握，只知道送貨情況。

還有很多人抱怨緝毒局的規(guī)定太不明確或太模糊，很多抱怨其實(shí)很有道理。2016年，緝毒局主管恰克·羅森伯格承認(rèn)對(duì)批發(fā)商的處理有些“模糊”。

馬辛在監(jiān)獄里服刑，緝毒局正緊鑼密鼓地布置執(zhí)行計(jì)劃。根據(jù)緝毒局的檔案，馬辛的濫用藥物處方并非憑空發(fā)生。緝毒局認(rèn)為有人協(xié)助，也有人慫恿馬辛。最明確地說(shuō)，馬辛的同謀包括彼得斯伯格商業(yè)街上連續(xù)三代家庭經(jīng)營(yíng)的藥店Judy’s，另外一個(gè)就是該藥房主要供應(yīng)商，麥克森。

這就是2012年犯罪檢舉人和緝毒局探員向麥格尼格爾匯報(bào)的內(nèi)容。麥格尼格爾批準(zhǔn)詳查。

彼得斯伯格沒(méi)幾家藥店。馬辛大部分需要止疼的病人都會(huì)去Judy’s開(kāi)藥，他自己也經(jīng)常早上過(guò)去取藥。這種關(guān)系在麥格尼格爾看來(lái)有些可疑（另外值得懷疑的是Judy’s最近在穆?tīng)柗茽柕滦麻_(kāi)了一家店面，離馬辛的診所很近）。檢察官感覺(jué)小鎮(zhèn)上這家藥店有些不對(duì)勁。

“在這種小鎮(zhèn)上住，肯定什么事都知道，”馬格尼格爾說(shuō)。他身材修長(zhǎng)，脾氣溫和，偶爾有些冷幽默?！耙f(shuō)這家藥房不知道馬辛做了些什么，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.”

2014年12月，Judy’s因不當(dāng)配藥與司法部達(dá)成200萬(wàn)美元的民事和解協(xié)議。Judy’s未承認(rèn)有不法行為，不過(guò)同意遵守更嚴(yán)格的匯報(bào)制度，現(xiàn)在仍在執(zhí)行。Judy’s的一位代理律師表示藥劑師都認(rèn)為所有配藥行為都是合法的，還指出緝毒局沒(méi)有采取行動(dòng)針對(duì)藥劑師。

Judy’s最老一家店成立于1965年，直到今天仍在營(yíng)業(yè)，是彼得斯伯格中心一座小磚房。（在穆?tīng)柗茽柕碌牡昝嬉呀?jīng)關(guān)閉。）最近有個(gè)周五我路過(guò)藥店，看到一位老年女性站在收款臺(tái)后，面前是一排排列整齊的塑料袋，里面都裝好了藥等人來(lái)取。

處理完Judy’s之后，麥格尼格爾和團(tuán)隊(duì)下一個(gè)目標(biāo)就是麥克森的經(jīng)銷中心，距離馬里蘭州蘭都弗車程三小時(shí)的經(jīng)銷中西負(fù)責(zé)向Judy’s送貨。

其實(shí)緝毒局調(diào)查員林德賽·馬洛庫(kù)早就注意到麥克森在蘭都弗的經(jīng)銷中心。馬克森在緝毒局駐華盛頓辦公室工作，之前就發(fā)現(xiàn)麥克森的可疑訂單匯報(bào)有些奇怪，因?yàn)橐粋€(gè)都沒(méi)有。從來(lái)沒(méi)提過(guò)Judy’s，也沒(méi)提過(guò)其他幾百個(gè)送貨的藥房，雖然送往該地的處方止疼藥數(shù)量持續(xù)攀升。對(duì)任何批發(fā)商來(lái)說(shuō)，一筆可疑訂單都沒(méi)有也不太正常。但麥克森真這么干了，還是全國(guó)最大的藥品經(jīng)銷商。（后來(lái)經(jīng)過(guò)仔細(xì)檢查記錄，緝毒局發(fā)現(xiàn)了好些漏掉的報(bào)告。）

麥克森可疑訂單報(bào)告的明顯缺失讓人想起之前一次調(diào)查。當(dāng)時(shí)調(diào)查內(nèi)容是麥克森向六個(gè)地區(qū)的小型家庭客戶運(yùn)送過(guò)量氫可酮和其他管制藥品，客戶服務(wù)對(duì)象是網(wǎng)絡(luò)藥店。麥克森并未報(bào)告相關(guān)可疑訂單。2008年麥克森跟司法部達(dá)成1325萬(wàn)美元的和解協(xié)議，但沒(méi)有承認(rèn)違法行為。但當(dāng)時(shí)緝毒局代理負(fù)責(zé)人米歇爾·雷昂哈特強(qiáng)烈指責(zé)了麥克森的行為：“麥克森公司推動(dòng)了全國(guó)處方藥濫用問(wèn)題的爆發(fā)性增長(zhǎng)?！?

2008年的和解協(xié)議中還要求麥克森打造有效的防控系統(tǒng)，確保以后不再犯同樣的錯(cuò)誤。所以當(dāng)年麥克森啟動(dòng)了管制藥品監(jiān)控項(xiàng)目（CSMP）。三層系統(tǒng)中，麥克森每類客戶每月購(gòu)買管制藥品都有相應(yīng)標(biāo)準(zhǔn)。如果超過(guò)標(biāo)準(zhǔn)，訂單會(huì)遭屏蔽而且引發(fā)審核流程。如果導(dǎo)致超過(guò)標(biāo)準(zhǔn)的原因很緊急，麥克森會(huì)提供藥品并且在特定情況下會(huì)提升標(biāo)準(zhǔn)；如果沒(méi)有合理原因，該訂單會(huì)轉(zhuǎn)往當(dāng)?shù)氐暮弦?guī)官員。如果合規(guī)官認(rèn)為訂單可疑，訂單將轉(zhuǎn)回麥克森的企業(yè)合規(guī)團(tuán)隊(duì)。如果該團(tuán)隊(duì)同樣認(rèn)為訂單可疑，麥克森將匯報(bào)給緝毒局。

不過(guò)，馬洛庫(kù)審查緝毒局處理蘭都弗經(jīng)銷中心的案例時(shí)發(fā)現(xiàn)，很明顯麥克森的合規(guī)系統(tǒng)沒(méi)起到作用。2011年7月，她要求麥克森提供20分左右有關(guān)可疑藥房的資料。當(dāng)年冬天，麥克森顯然也意識(shí)到出了問(wèn)題；很短時(shí)間里，麥克森蘭都弗經(jīng)銷中心就向緝毒局提交了318份可疑訂單，設(shè)計(jì)之前的月份和星期。政府則認(rèn)為對(duì)于如此大規(guī)模的經(jīng)銷中心，可疑訂單的數(shù)量太少了，而且匆忙補(bǔ)交顯得仿佛承認(rèn)有問(wèn)題。

麥格尼格爾和馬洛庫(kù)當(dāng)時(shí)都不知道，但當(dāng)時(shí)全國(guó)其他地方也在進(jìn)行類似調(diào)查。另一起位于科羅拉多州奧羅拉，麥克森在當(dāng)?shù)氐慕?jīng)銷中心也是2008年和解協(xié)議中提到過(guò)的。2012年3月科羅拉多經(jīng)銷中心有一次引起檢察官的關(guān)注，當(dāng)時(shí)該經(jīng)銷中心向緝毒局匯報(bào)了一些可疑訂單，都是關(guān)于同一個(gè)藥房，這也是2009年以來(lái)公司首次提交可疑訂單。

不管在蘭都弗還是奧羅拉，兩地經(jīng)銷中心都發(fā)出了不少管制藥品。政府報(bào)告顯示，兩家中心都沒(méi)想過(guò)訂單“可不可疑”，也沒(méi)提醒緝毒局注意。

合規(guī)文件透露了很多信息。文件顯示麥克森管理合規(guī)項(xiàng)目態(tài)度很隨便。藥房觸及標(biāo)準(zhǔn)后，經(jīng)銷中心總是很容易就能通過(guò)審核流程。客戶需要?dú)淇赏睦碛山?jīng)常很模糊，而且毫不可信——“可以提升客流量”；“增加生意”等。他們就這樣拿到了藥。

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.

對(duì)麥格尼格爾來(lái)說(shuō)，事情很簡(jiǎn)單。“他們不夠重視，”他說(shuō)?！拔腋铱隙](méi)人惡毒地希望大街上麻醉劑泛濫。企業(yè)有時(shí)就是太追求銷售成績(jī)，忽略了可疑訂單?！?

麥克森方面則表示此類指責(zé)都是莫須有，宣稱公司遵守所有法律法規(guī)。此外，麥克森一位發(fā)言人還表示“在麥克森，管制藥品銷售從來(lái)沒(méi)有跟銷售人員激勵(lì)直接掛過(guò)鉤?！?

關(guān)于麥克森的調(diào)查一直在加碼。到2014年夏天，全美12個(gè)地區(qū)的檢察官都在調(diào)查麥克森是否存在違反《管制藥品法》的行為。

麥格尼格爾表示，據(jù)政府保守估計(jì)，近四年時(shí)間里麥克森在12個(gè)地區(qū)瞞報(bào)的可疑訂單數(shù)量達(dá)數(shù)萬(wàn)筆。問(wèn)題只剩下會(huì)罰多少。檢察官認(rèn)為罰金應(yīng)該天價(jià)才能起到明顯的警告作用，1.5億美元應(yīng)該可疑?！耙环冈俜甘钦嬲拇髥?wèn)題，” 麥格尼格爾表示。“不僅麥克森，別家也一樣。如果1300萬(wàn)美元罰金沒(méi)讓他們吸取教訓(xùn)，那就得給點(diǎn)別的處罰，是吧？只有高額罰金、停業(yè)和嚴(yán)格遵守規(guī)定才能根本解決問(wèn)題。”

后來(lái)，麥克森重新梳理了一遍監(jiān)控項(xiàng)目，而且據(jù)說(shuō)在遵守規(guī)定方面加倍努力。

負(fù)責(zé)具體工作的是加里·博格斯，2013年加入麥克森之前曾在美國(guó)緝毒局工作四十年，在政府對(duì)麥克森啟動(dòng)調(diào)查期間擔(dān)任監(jiān)管事務(wù)高級(jí)主任?，F(xiàn)在麥克森的管制藥品監(jiān)管項(xiàng)目已有40名工作人員，其中很多都跟博格斯一樣具有監(jiān)管部門背景。

此外麥克森也在技術(shù)方面投入巨大，例如完善的分析系統(tǒng)以識(shí)別可疑訂單。在博格斯領(lǐng)導(dǎo)下，麥克森開(kāi)始投入更深入也更積極的盡職調(diào)查工作，可以一系列跟麥克森客戶相關(guān)的訴訟看出來(lái)，相關(guān)客戶都是2013年到2014年間管制藥品突然遭麥克森斷供的。

和解過(guò)程也促進(jìn)了麥克森跟緝毒局的合作。雙方都表示如今合作比較順暢。（過(guò)去幾年里緝毒局藥品濫用管控辦公室與行業(yè)的協(xié)作非常深入。）

2015年，漢默格倫認(rèn)為麥克森應(yīng)該就止疼藥濫用問(wèn)題積極與監(jiān)管層展開(kāi)對(duì)話。有些人可能認(rèn)為麥克森只是問(wèn)題一部分，但漢默格倫認(rèn)為鑒于麥克森在醫(yī)療系統(tǒng)中的領(lǐng)導(dǎo)地位，應(yīng)該為解決問(wèn)題貢獻(xiàn)力量。所以去年他調(diào)派幾十名員工成立工作組，起草了一份白皮書，主要在華盛頓發(fā)行。文件提出六點(diǎn)建議。其中包括打造全國(guó)病患安全系統(tǒng)，該系統(tǒng)基于數(shù)據(jù)，幫助藥劑師和醫(yī)生實(shí)時(shí)鑒別可能存在濫用藥物風(fēng)險(xiǎn)的病人。

可能有些奇怪，但馬辛在監(jiān)獄里過(guò)得很好。監(jiān)獄位于西弗吉尼亞格倫威爾，監(jiān)控級(jí)別為中高級(jí)，獄中人們叫他“醫(yī)生”，其他囚犯跟他講了很多如何騙醫(yī)生開(kāi)出氧可酮之類處方藥的故事。人們?yōu)榱伺師o(wú)所不用其極，讓馬辛大開(kāi)眼界，后來(lái)他獲得美國(guó)聯(lián)邦監(jiān)獄局批準(zhǔn)撰寫了藥物濫用如何發(fā)生的教材。（他的兒子提供了很多研究材料，他在獄中的牢友之前是海洛因販子。兩人都在書中獲得了作者致謝。）2014年馬辛因表現(xiàn)良好提前獲釋，當(dāng)時(shí)馬辛跟團(tuán)隊(duì)已經(jīng)寫出了第二本手冊(cè)，內(nèi)容是犯人在獄中濫用藥物。

平時(shí)不做宣傳防范藥物上癮工作時(shí)，馬辛的時(shí)間都花在跟朋友韋德·羅哈波夫合作開(kāi)設(shè)的公司上，主要產(chǎn)品叫“猛禽”?！懊颓荨笔且惶紫到y(tǒng)，其中包括生物識(shí)別、電子病歷，還有可錄制視頻的眼鏡，主要用來(lái)幫助醫(yī)生避免開(kāi)出濫用藥物的處方。如今他正向醫(yī)學(xué)委員會(huì)推介“猛禽”。

馬辛對(duì)依法服刑心存感激，不僅僅是因?yàn)榫攘怂幻?。他不僅戒除了藥癮，而且了如果他繼續(xù)濫用藥物，可能已經(jīng)因病喪命。去年馬辛發(fā)現(xiàn)罹患致命的血管瘤。（馬辛的父親曾因動(dòng)脈瘤破裂導(dǎo)致后來(lái)一直癱瘓。）馬辛主要的癥狀是劇烈頭痛，他之前吃止疼藥時(shí)從來(lái)沒(méi)感覺(jué)過(guò)。2015年7月，他在西弗吉尼亞大學(xué)附屬醫(yī)院接受了微創(chuàng)手術(shù)，名叫WEB血管瘤栓塞系統(tǒng)。這是一種全新的手術(shù)，尚未獲得食品藥品監(jiān)督局批準(zhǔn)，馬辛是首批接受手術(shù)的患者。

如今馬辛健康且清醒，他表示“能重獲機(jī)會(huì)在對(duì)抗藥品濫用領(lǐng)域工作非常興奮，也充滿感激，今后要努力幫助更多深陷上癮癥的人們。”

再回到麥克道威爾，警長(zhǎng)韋斯特正等著好消息。自從縣里提交了對(duì)藥品經(jīng)銷商的訴訟，西弗吉尼亞好幾個(gè)縣和鎮(zhèn)，還有一些外地的機(jī)構(gòu)也跟著提交了訴訟，例如奧克拉荷馬州的切諾基部落。三大經(jīng)銷商也在忙著應(yīng)訴，均表示指控沒(méi)有根據(jù)。

隨著公共醫(yī)療危機(jī)日益嚴(yán)重，議會(huì)也在詢問(wèn)麥克森和同行的行為是否失當(dāng)。今年5月，眾議院能源和商業(yè)委員會(huì)啟動(dòng)調(diào)查，著重查藥品經(jīng)銷商在西弗吉尼亞的“藥品傾銷”行為。三大經(jīng)銷商都已收到質(zhì)詢函，要求6月8日之前答復(fù)。

韋斯特深信訴訟會(huì)收到很大成效，至少他在努力對(duì)抗藥品濫用之災(zāi)?！按丝涛覞M懷希望，也誠(chéng)心禱告減輕人們的痛苦，不僅為西弗吉尼亞人，更是為美國(guó)各地的人們?！彼硎??！斑@是一場(chǎng)大型瘟疫，值得嚴(yán)肅對(duì)待?！?

本文另一版本刊登于2017年6月15日出版的《財(cái)富》雜志。（財(cái)富中文網(wǎng)）

譯者：Pessy

審稿：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.