Tug Valley Pharmacy was late to the gold rush, but swiftly made up for lost time.

To the watching investigators, the stone building with a peaked red roof looked more like a rural cabin than a fount for the millions of opioid pills spilling across Appalachia. The giveaway was the drive-thru window, and the cars lined up past the abandoned ghost shops in downtown Williamson, West Virginia.

The name of the pharmacy’s owner, Samuel R Ballengee PharmD, was displayed on the window under a sales pitch: “It’s all in the bag.”

“Let’s call this whole thing what it is. It’s pretty much a cartel. A drug trafficking organisation,” said Sgt Mike Smith of West Virginia state police, who spent years unravelling the web of doctors, pharmacists and drug companies that made rural Mingo county the opioid capital of America.

“Then right in the middle of this drug trafficking organisation, you have a little pharmacy that pops up and everybody’s OK with it. I’m sitting here looking at this. It’s hard to believe that was allowed.”

It wasn’t long before drug distribution companies, some of the largest firms in America among them, were delivering millions of opioid pills a year to Tug Valley. Millions more were shipped to another pharmacy, Hurley’s Drug Store, four blocks away. All in a town of fewer than 3,000 people.

The Tug Valley Pharmacy. Photograph: Chris McGreal

Twenty minutes’ drive to the north, the Sav-Rite Pharmacy in the village of Kermit, population 280 and falling, was outstripping them both.

Drug distributors delivered more than 30m opioid pills just to those three pharmacies, in one of the poorest counties in America. Ballengee and the other drug store owners kept escalating the orders, and the distributors filled them without flinching. They shipped more narcotic painkillers to Mingo county per head of population than to any other place in the US.

Opioid makers such as Purdue Pharma and Johnson & Johnson shaped the medical culture that drove the surge in prescribing of narcotic painkillers that caused today’s drug epidemic. Doctors wrote the prescriptions. But at the front end were thousands of pharmacies dispensing the pills, and among the pharmacists were profiteers.

No questions asked

In 2001, the West Virginia bureau of criminal investigation sent Smith to investigate a surge of opioids pills on the streets. At first he planned to approach it the way he investigated marijuana: by working along the chain from the user to the dealer to the producer with the threat of jail to prise information from suspects.

But Smith quickly discovered that users were happy to tell him where he could find doctors to write prescriptions and drug stores to fill them – no questions asked. They pointed him to Mingo county.

Smith went and watched. Each day, hundreds of people lined up outside an old animal feed store where a group of doctors were set up by a former pimp, just out of federal prison for running a gay prostitution ring in Washington DC, to churn out opioid prescriptions faster than West Virginia’s major hospitals.

Before long, people in town were calling the Williamson Wellness Center a “pill mill”.

The doctors were careful to insist their prescriptions were filled only at pharmacies that would take the money and not ask questions. But as word spread and people came from hundreds of miles around, so the drugstores struggled to meet demand.

Then, in a town where department stores shut years ago and traditional main street stores gave way to personal injury lawyers, a new drugstore popped up.

“Suddenly Tug Valley opens, out of the blue, in 2006. And there are big lines from the first day,” said Smith.

Before long, it was outselling its rivals in town.

In the six years after Tug Valley opened, pharmaceutical distributors delivered nearly 11m of the most common type of opioid pill, hydrocodone. Month by month, the orders escalated. In 2009 alone, Ballengee ordered 3m hydrocodone pills. Hurley Drug was dispensing nearly as fast.

Across the river, Family Pharmacy was so busy that the owner, Larry Ray Barnett, had hundreds of bottles of pills lined up ready for assistants to grab as customers cycled through.

The Wellness Center was churning out so many opioid prescriptions that the fax machine couldn’t keep up with transmitting them individually to the pharmacies. So the clinic didn’t bother to send prescriptions at all and took to the illegal practice of writing lists of names and dosages on sheets of paper and faxing them to the pharmacies.

Investigators discovered the pharmacies lined up bottles pre-filled with set amounts of pills.

“The list comes in, you print out the name, slap a tag on the bottle. There you go,” said Smith.

‘Greed took over’

In the north of Mingo county, another pharmacist looked on enviously. James Wooley got so little business at his drugstore in the village of Kermit in the early 2000s that he also ran a used car business next door.

“He’s a fine fella,” said Charles Sparks, Kermit’s mayor then and now. “You couldn’t beat him as a person. But he just got into that other business, and it starts snowballing and greed took over. You know how it is: if I can make a million, I can make two.”

Wooley decided to follow the Williamson model by setting up a doctor to churn out opioid prescriptions for him to fill. The pharmacist persuaded his assistant at the drugstore, Debra Justice, to set up a medical clinic just outside Kermit and they recruited a doctor more than an hour away at Marshall University’s medical school, Dr John Tiano. All he had to do was lend his name to the prescriptions and one of the nurses at the clinic would fill it out.

The Justice Medical Complex opened in the spring of 2005, a 10-minute drive from Kermit. Prescriptions were sent directly to Wooley’s pharmacy, the Sav-Rite. The circle was complete.

Within a few months, Wooley was filling an opioid prescription a minute in a town of fewer than 400 people. The pharmacy bought more of the opioid than any drugstore in West Virginia or neighbouring states that year and ranked 22nd in the nation among retail pharmacies for hydrocodone purchases. Gross sales surged above $6.5m.

Sparks, the mayor, watched the influx.

“Oh, we were aware. We knew what was going on. The citizens would come and say, ‘Why don’t you do something about that up there?’ The average person doesn’t know or doesn’t stop and think that you can’t just go in. You have to do an investigation before you can stop something like that. People said nothing’s being done.”

Missed opportunities

The two decades of the opioid epidemic is a story of missed opportunities, large and small.

If the warnings sounded by pain specialists and doctors in the first few years had been heeded, the crisis might have been averted or at least greatly diminished. If federal regulators had intervened to limit prescribing of high-strength opioids to those who really needed them, there would have been far fewer pills on the streets.

West Virginia’s medical regulators missed opportunities too. In 2007, someone anonymously tipped off the West Virginia medical board that Tiano was prescribing illegally. The board’s punishment was to require him to write a “book report” on a medical textbook called Responsible Opioid Prescribing: A Physician’s Guide.

Marshall University forced Tiano to stop moonlighting at the clinic. On his way out the door, having made more than $250,000 from opioid prescribing in just two years, the doctor recruited his successor, Dr Augusto Abad, who lived 90 minutes away in the state capital, Charleston, and rarely saw patients. But plenty of prescriptions were written in his name.

By then, Smith was watching. He worked with an FBI agent, Joe Ciccarelli, with a long history of drug investigations. Ciccarelli had come from pursuing Colombian cartels in Florida, but he already knew West Virginia well from working the drug beat as a police officer in the early 1980s.

“These junkies would forge prescriptions, and back in the pre-computer days I can remember standing in pharmacies going through prescriptions going, ‘that’s a junkie, that’s a junkie, these are false scripts’,” said Ciccarelli, who has since died, in 2017.

An informant tipped them off that Debra Justice and Wooley had hatched a get rich(er) quick scheme to open a pain clinic that would refer all of its prescriptions for controlled substances to Sav-Rite Kermit, and that they were “handing out drugs like candy”.

Mary Ann Withrow, a federal agent, said investigators recorded that the Sav-Rite and the clinic were “excessively busy” for such a small town.

One undercover agent noted that the cash drawer at the Sav-Rite was so full the assistant couldn’t close it. Something similar was going on at the Tug Valley Pharmacy and Hurley’s in Williamson.

“It looked like a carnival,” said Smith. “There’s no way people down there didn’t know what was going on. There was a lot of money being made.”

Federal charges

Years later, all of the pharmacists claim to have not seen any of this.

Ballengee was arrested in July, days after an Ohio court released Drug Enforcement Administration documents showing that pharmaceutical distributors delivered millions of opioid pills to his tiny pharmacy.

Federal prosecutors charged him with making millions of dollars from illegally supplying opioids alongside Anthony Rattini, the former president of Ballengee’s major suppliers, Miami-Luken, and others. Rattini is accused of distributing narcotic painkillers illegally to more than 200 pharmacies across West Virginia, Ohio, Indiana and Tennessee.

Ballengee testified in earlier civil depositions that he was filling between 150 and 200 opioid prescriptions a day from the Wellness clinic alone, but claimed to see no reason for suspicion. He denied knowing that the clinic was widely spoken about in town as a “pill mill”. He also said he was unaware that Williamson was nicknamed “Pilliamson”, or that a doctor who was one of the main prescribers was known as “Pill Billy”.

Barnett, who owned Family Pharmacy, also professed not to know the reputation of the Wellness Center or that it had a list of acceptable pharmacies for patients to fill opioid prescriptions and that his was on it. Like Ballengee, he claimed not to know about the reputation of the prescribing doctors, including one who was described in a local newspaper as “a danger to the community because he prescribed thousands of addictive pills without legitimate purpose”. He saw no red flags even as the prescriptions poured in by fax and phone.

Under oath, Wooley said he didn’t remember ever seeing articles in trade magazines warning about escalating opioid addiction, or patients going from one doctor to another in search of multiple prescriptions.

Smith went to federal prosecutors with the evidence about the illegal lists of prescriptions and pressed them to file charges. The policeman said it fell under the definition of wire fraud.

“I tried to use the wire fraud to get everybody, the pharmacies and the doctors. They didn’t go for that,” he said.

So he went to the West Virginia board of pharmacy.

“They said I was right in what I was alleging. However, what they did is they talked to the pharmacists and told them they couldn’t do that any more,” he said. “The whole thing was a game, a scam. Everyone was going along with it.”

Eventually, the FBI and state police moved in on the Sav-Rite in Kermit in 2009, arresting Wooley.

“We’re standing out there with a couple of uniformed troopers and cars just keep going up,” said Ciccarelli. “Where are you from? I came from Point Pleasant. OK, let’s see. You passed about three hospitals, probably 50 pharmacies, and you’re driving 100 miles from Point Pleasant to Kermit to pick up a prescription? It’s things like that you can put in front of a jury and they’re going to go, that ain’t right. You stack those things up and a jury’s finally going to say, I don’t believe this.”

Wooley pleaded guilty to illegally selling prescription medication and conspiracy, and went to prison for six months in 2012. The doctors at the clinic he set up were each jailed for a year. Tiano lost his medical licence. On his release, Abad was deported to his home country, the Philippines, where he continues to practise.

“It boggles my mind,” said Sparks, the mayor. “I was blown away. I thought, ‘My God, almost 9m pills in two years went out of here, and Wooley said that he made $500,000 a month in a little town of 400 people.’”

The following year, the FBI and state police raided the Williamson clinic, arrested doctors and cut off the opioid pipeline. The numbers of prescriptions fell sharply.

In 2016, a major drug distributor, McKesson abruptly ended its contract with Tug Valley Pharmacy when West Virginia’s attorney general, Patrick Morrisey, filed a lawsuit against the company accusing it of recklessly distribution millions of pills across the state. Earlier this year, McKesson paid the state $37m to settle the suit. In 2017, the West Virginia board of pharmacy dismissed its director for failing to properly regulate the flood of opioids to the state’s pharmacies and investigate suspicious deliveries.

Prosecutors prepared charges against Barnett, but he died before he could be brought to trial.

Up until his arrest, Ballengee continued to insist that he was doing no more than filling prescriptions written by doctors. He is now awaiting trial.

Chris McGreal is the author of American Overdose, The Opioid Tragedy in Three Acts