In a former Kmart, on a worn-out stretch of North Charleston's urban sprawl, a mail-order pharmacy run by the Department of Veterans Affairs shipped more addictive opioid painkillers than any pharmacy in the country.
More than half a billion pain pills coursed through its mail-order warehouse between 2006 and 2012 — a pace of hundreds of thousands per day as drug makers allegedly carried out an orchestrated effort to market their painkillers to veterans.
Even as evidence of opioids’ addiction-causing qualities mounted in the early 2000s, the VA told its patients that pain was an untreated epidemic that could be managed safely with narcotics.
Nearly all of the opioids prescribed to VA patients in the United States between 2006 and 2012 stopped at this North Charleston warehouse before the VA shipped them to veterans’ doorsteps and mailboxes, newly released federal data shows.
The North Charleston facility is one of only seven mail-order pharmacies operated by the VA in the United States. For many years, the local warehouse was the only VA operation in the country that sent massive quantities of opioids through the mail, passing through a nondescript shopping center fronted by a boarded-up fast-food joint and a prepaid phone store.
These findings come as a wave of lawsuits has been filed against drug industry giants, including Purdue Pharma, Endo Pharmaceuticals and Johnson & Johnson. The suits prompted the release of documents, filed as evidence, offering an inside view of how companies directed their messaging to veterans.
“If you went to the doctor, they gave you a pain pill,” said Vietnam veteran Lawrence Ross, an 83-year-old Charleston resident.
Ross lost a leg to diabetes in the mid-2000s. He left a Mount Pleasant recovery center with a packet of pain pills. Later, his doctor prescribed OxyContin and Percocet following a hip replacement.
The medicine made him nauseous and acquaintances harassed him for leftover pills, so he flushed them down the toilet. Meanwhile, other veterans fell victim to the drugs' addictive pull. Between 2010 and 2016, researchers found overdose deaths among veterans climbed 65 percent.
The DEA dataset showing opioid distribution became public after two newspapers — The Washington Post and The Gazette-Mail of Charleston, W. Va. — argued in federal court for its release. The information finally became public in mid-July.
The data offers a glimpse into the past. Since 2012, the VA has launched an opioid safety initiative and its painkiller prescription rates have been falling.
“Pain medications are often an important part of treatment but their use — particularly for opioids — must be managed properly to keep our Veterans safe from the risks of addiction,” Scott Isaacks, director of the local Ralph H. Johnson VA Medical Center, wrote in a blog post last week.
The VA has not answered detailed questions about its prescribing policies and its system of mail-order pharmacies. A public records request made by The Post and Courier has not yet been fulfilled.
'Those who have served'
In the early 1990s, the nonprofit American Pain Society spread the message that opioids were the answer to untreated pain. In fact, the Pain Society said, pain should be viewed as the “fifth vital sign," alongside a patient's pulse and breathing, body temperature and blood pressure.
The VA endorsed the group’s idea in 2000 when it published a guide instructing its providers to rate patients’ pain on a 0-to-10 scale. The guide chided providers who gave a low priority to pain care. "Restrictive regulation" of the medications, along with "fear of addiction," were roadblocks to treatment, the VA document explained.
Now, an army of lawyers representing states across the country is arguing the American Pain Society was a front group for the pharmaceutical industry. It filed for bankruptcy and shut down in June, citing "numerous spurious lawsuits."
It wasn’t the only group with industry ties that allegedly targeted veterans.
The American Pain Foundation, another industry-financed nonprofit, published a book that beckoned veterans toward opioids. The book, titled "Exit Wounds," downplayed the risk of addiction and omitted the possibility of deadly interactions with anti-anxiety drugs.
Its author, Derek McGinnis, called opioids "the gold standard of pain medications," describing their main side effects as constipation, nausea and vomiting. It also minimized the benefits of household painkillers like acetaminophen and emphasized their risks, like kidney failure and liver damage.
“The pain-relieving properties of opioids are unsurpassed,” wrote McGinnis, an Iraq War veteran. “Yet, despite their great benefits, opioids are often underused.”
At least 45 states, including South Carolina, have accused the drug industry of propping up the Pain Foundation, which shut down in 2012, to push its message. The state of Mississippi railed against "Exit Wounds" when it sued drug manufacturers in 2017, calling it "pure marketing" masquerading as a returning war veteran's story.
Thousands of copies were sent around the country, where they were sometimes distributed by veterans advocacy groups. In Oregon, for instance, the state helped hand out 5,000 books, vowing to send one to every veteran in the state. It remains for sale online.
The book was underwritten by a trio of drug manufacturers, and the overwhelming majority of the American Pain Foundation's funding came from the health care industry, according to its annual reports to donors.
The group was tied to the VA, too. One of the physicians associated with the foundation was national director of pain management for the Veterans’ Health Administration until 2016, and he is still employed at the VA.
The year after "Exit Wounds" came out, one company, Endo Pharmaceuticals, contributed more than $1 million to the Pain Foundation. The foundation, in turn, called Endo, a major manufacturer of generic drugs, a "visionary" contributor.
In North Charleston, meanwhile, more than half the painkillers that passed through the VA mail-order pharmacy came from Endo. Between 2006 and 2012, nearly 288 million of its opioid pills poured in. Endo did not respond to questions about the shipments or its role in the Pain Foundation.
No company sent as many pills to the pharmacy, but others sought to market their products to veterans.
Documents released through litigation reveal that Purdue Pharma made its way into VA conference rooms. Purdue budgeted $200,000 in 2001 to underwrite quarterly meetings of the VA's pain team and specifically targeted the agency in hopes of forming a "strategic alliance," the documents show.
Purdue sales representatives would later make routine visits to VA doctors. In Massachusetts alone, they went to VA facilities on average five times a month for six years, according to a Post and Courier analysis of their travel logs. Purdue didn't answer questions about the VA funding or its visits to doctors. In a statement, the company said it has "consistently worked to ensure it provides accurate, substantiated information to patients, including veterans who suffer from a high prevalence of chronic pain."
Soon after Janssen Pharmaceuticals, a subsidiary of Johnson & Johnson, had a new painkiller approved for sale in 2011, it set out to see if it could get the media to write about it. A consultant hired by the company suggested playing up the benefits to veterans returning from war, according to documents released by the Oklahoma attorney general.
The suggested pitch: “Those who have served, need to be served.”
In a statement, the company said the proposal didn't show wrongdoing because in Oklahoma's lawsuit, "there was no evidence presented that this strategy made it beyond one consultant's proposal, nor that Johnson & Johnson's marketing was otherwise intended to 'hook' veterans."
Around the same time as the pitch, an obscure group called the Imagine the Possibilities Pain Coalition held a meeting to talk about its goals, like how to “change the conversation about pain.” It suggested talking to veterans about pain and trying to erode “the paradigm of stoicism.”
Roughly half the coalition’s members worked for Johnson & Johnson, the documents released in Oklahoma show. In court papers, the company said the coalition was "Janssen-sponsored" but didn't last long. It says the group disbanded after four meetings when funding dried up.
The VA pharmacy in North Charleston doesn't appear to have shipped drugs made by Purdue and Johnson & Johnson because the government mostly buys generics.
Veterans weren’t the only group allegedly targeted by the industry's marketing campaigns. Women, injured workers and the elderly were singled out, too.
A mounting crisis
The VA has acknowledged that its doctors used to prescribe patients too many painkillers.
In 2012, nearly 680,000 VA patients — more than 10 percent of all patients who visited a VA facility that year — received an opioid.
Most VA patients who were prescribed painkillers took the drugs for months at a time. In 2012, 440,000 VA patients were on long-term opioid therapy, meaning they took pills every day to manage their chronic pain.
The heavy flow of opioids to veterans owes largely to how much chronic pain they tend to experience, according to Dr. Mark Edlund, an addiction researcher who has studied the VA for the research nonprofit RTI International.
But, in most cases, that pain doesn’t derive from combat injuries. The typical VA patient using opioids didn’t see war. Instead, most opioid users in the system are middle-aged men with arthritis and back pain, many of whom use the VA as a health care safety net.
“It’s much easier to write a prescription than to spend an hour explaining to somebody why and how,” said Dr. Robert Friedman, head of Charleston's VA pain clinic, in a 2017 interview with The Post and Courier.
As the VA cut down on opioid prescriptions, the department placed a newfound emphasis on proven alternative therapies.
But asking patients to drop a pain prescription in favor of acupuncture or lavender-scented Vaseline rubs isn’t always an easy sell.
“It’s a lot more labor-intensive,” Friedman said.
The VA prides itself on the fact that it became the first hospital system in the country in 2018 to publicly post its opioid prescribing rates. The department would not provide any data related to opioid prescriptions prior to 2012, however. The Post and Courier submitted a Freedom of Information Act request to obtain the information. It has not been answered yet.
For nearly two decades, medical evidence was mounting that opioids could be addictive.
As early as 2001, federal investigators were aware of the dangers of over-prescribing. In June that year, the DEA shut down a pain management clinic in Myrtle Beach that was doling out Oxycontin prescriptions to hundreds of patients who walked through the door.
A New York Times report from 2001 cited hundreds of overdose deaths were tied to the painkiller, which had only been approved by the FDA six years earlier.
“No other drug in the last 20 years has been abused more widely so soon after its introduction,” the 2001 article explained.
According to Edlund's analysis of 2012 data, about half of VA patients who were prescribed opioid painkillers took them at least three months out of the year. That’s a key measure because most patients who take opioids for that long end up taking them for years.
Edlund's research found only one in 13 patients who got a long-term opioid prescription quit after a year.
“Once people had received three or four prescriptions, it was likely that it just continued long-term,” Edlund said.
The VA was forced to publicly reckon with its prescribing practices in 2014 when Marine veteran Jason Simcakoski died of a drug overdose at a VA facility in Wisconsin after being prescribed multiple opioids. The facility's chief of staff was fired. Congressional inquiries followed.
A VA report published earlier this year acknowledged people with an opioid use disorder are 13 times more likely to die by suicide. What’s more, the rates of suicide among veterans with this illness increased by about 50 percent between 2001 and 2014.
Those trends are due, in part, to the fact that 93 percent of veterans who receive a chronic opioid prescription are also prescribed a benzodiazepine for anxiety. Combined, those drugs form a dangerous cocktail that increases the likelihood of death by overdose.
Waiting for the mail
John Frye’s battle with opioids nearly made him one of the more than 6,000 veterans to die by suicide every year.
At the peak of his addiction to opioids, he attempted suicide, swallowing dozens of the pills and several bottles of beer.
Someone found the Navy veteran and saved his life.
At that point, he had been taking opioid pills prescribed by VA doctors for several years. Frye was hit by a car while riding his bike in 2007, which was when the prescriptions began. He already had a history of addiction.
Even when he lived in Ohio, pills arrived in the mail from North Charleston. He would get 60 Lortab at a time. Three or four times in the 10 years he received the drugs, he said he called the VA to complain that the Lortab had never shown up — a lie he told to double-up on the drugs. The refills continued to arrive in the mail.
“I’d be at the mailbox two hours before the mailman got there to get those pills,” he said.
Frye, 62, moved to Charleston in 2010, where he continued to get opioids through the mail.
In 2013, the same year he attempted suicide, Frye was arrested and jailed for vandalism. He'd lost his home. A judge sent him to treatment for his disorder at the local VA after 20 months of his sentence.
He hadn’t asked for treatment for his use disorder before. Today, he is sober. But the effects of his addiction continue to follow him. Because the VA has documented his history of addiction, they will not prescribe him opioids anymore. Even when Frye needed dentures and had to have all 32 teeth pulled, he received only ibuprofen.
'Meds by Mail'
By 2013, retail pharmacies were under pressure to halt the flow of opioids. This frustrated drugmakers like Purdue Pharma, documents from the Massachusetts attorney general show.
Walgreen’s agreed to stop offering incentives for its employees to fill opioid prescriptions in a settlement with the DEA. And wary pharmacists were beginning to call physicians to question prescriptions.
A consulting firm had one idea to help Purdue Pharma overcome this problem. Mail-order centers, like the VA facility in North Charleston, could help the company circumvent retail pharmacies altogether.
It is unclear whether Purdue acted on the strategy. The data released by the DEA only runs through 2012.
Prescriptions have been sent through the mail in the U.S. for more than a century. The VA pioneered the use of large-scale mail-order pharmacies in 1946 so it could send medications to patients as a free benefit.
Private industry caught onto the idea, and during the 1980s, mail service pharmacy sales grew from less than $100 million at the beginning of the decade to roughly $1.5 billion in 1989.
In the early 2000s, the VA adopted a machine the cosmetics industry used to process drug orders even more quickly — at a rate of 1,200 to 1,400 per hour. By 2001, all of the VA's consolidated mail-order pharmacies began shipping controlled substances, according to an audit by the VA Inspector General.
The system, called "Meds by Mail," is meant to make sure veterans can get refills on their non-urgent prescriptions. It’s free for patients — no deductibles, no copay.
The VA dispenses about 80 percent of its prescriptions through the mail, which take an average 2½ days to arrive. When the DEA upgraded opioids to a Schedule 2 narcotic in 2014, federal rules prohibited them from being sent through the mail. Today, the VA doesn't mail Schedule 2 drugs.
But through the early 2000s, they did ship opioids. While painkillers poured through North Charleston, the deluge seemed to slip past members of Congress. The use of painkillers registered few mentions in the Veterans Affairs committees of the House and Senate.
The first in-depth hearing on veterans’ opioid use didn’t come until 2014. The VA’s top health official testified that the agency had been swept up in inflated concerns about untreated pain. Those concerns had led to a surge in opioid prescriptions across the American health care system.
'A targeted part of our society'
Ross, the Air Force retiree, is exactly the sort of older veteran who became the target of opioid manufacturers and distributors.
He spent 25 years in the service. It wasn’t until after he retired that chronic pain became a problem. The VA prescribed him OxyContin and Valium at intervals, but now he treats his own pain by rubbing his sore spots with hemp oil.
“That stuff there is a big, big help,” he said of the oil. “And it’s not costing the VA a penny.”
It's exactly the kind of pain management the VA wants to promote today.
Doctors in the veteran health system have one key advantage, said Edlund, the opioid researcher. Because the VA is a self-contained health system, it can track their patients’ full medical history. That means physicians can see if their patients might be at risk for substance abuse, and if they’ve been prescribed painkillers by other VA doctors.
The Government Accountability Office noted a decline in opioid prescriptions in a 2018 report. But it wrote in a report last year the VA hadn’t met all of the goals it laid out in 2013.
The agency listed nine objectives. Six years later, three of those goals haven’t been met yet, said Mary Denigan-Macauley, acting director of the GAO’s health care division.
Government auditors remain concerned about inconsistencies in the VA’s opioid prescribing policies, Denigan-Macauley said.
For instance, the GAO looked at the medical records of 53 veterans who had 90-day supplies of opioids. The VA failed to check 40 of those veterans’ drug histories, and 21 of the patients hadn’t taken a urine test in at least a year. The oversight agency is also pushing the VA to put “pain champions” in place at its facilities to keep tabs on opioid safety.
While more of these pills flowed through North Charleston than any other center in the country, South Carolina has not been hit by the opioid epidemic as hard as other states. The rate of opioid prescriptions peaked in South Carolina in 2012, when enough of the painkillers were being distributed for every citizen of the state to have at least one, according to the Centers for Disease Control and Prevention.
Charleston County, meanwhile, saw more deaths from opioid overdose in 2017 than any other county in the state.
In the past few years, a growing number of local governments have sued drug manufacturers and distributors, hoping to recover some of the money they spent coping with the epidemic.
Charleston attorney Joe Rice, of Motley Rice, is one of a few attorneys leading plaintiffs from across the nation in more than 2,000 cases. Charleston’s significant military population is one reason the county has seen a heavier toll from the epidemic, he said.
“That’s a targeted part of our society,” Rice said.
Jerrel Floyd, Emory Parker, Bryan Brussee and Glenn Smith also contributed to this report.