By Sari Horwitz, Steven Rich and Scott Higham

Death rates from opioids soared in the towns, cities and counties that were saturated with billions of prescription pain pills from 2006 through 2012, according to government death data and a previously undisclosed database of opioid shipments made public this week.

The highest per capita death rates nationwide from opioids during those years were in rural communities in West Virginia, Kentucky and Virginia. In those seven years, those communities also were flooded with a disproportionate share of the 76 billion oxycodone and hydrocodone pain pills from some of the country's largest drug companies, an analysis by The Washington Post reveals.

The national death rate from opioids was 4.6 deaths per 100,000 residents. But the counties that had the most pills distributed per person experienced more than three times that rate on average. Thirteen of those counties had an opioid death rate more than eight times the national rate, according to the government data. Seven of them were in West Virginia.

“What they did legally to my state is criminal,” Sen. Joe Manchin, D-W.Va., said. “The companies, the distributors, were unconscionable. This was not a health plan. This was a targeted business plan. I cannot believe that we have not gone after them with criminal charges.”

For the first time, The Post is able to reveal where prescription opioid pills were shipped county-by-county and compare that information with federal data that logs deaths caused by prescription opioids.

For instance, 267.7 million prescription pain pills were supplied in Multnomah County between 2006 and 2012. During that same time period, 141.9 million were distributed in Clackamas County and 132.5 million in Washington County. In each county, about half of the distributed pills were manufactured by SpecGx, a subsidiary of Mallinckrodt Pharmaceuticals.

Death rates from opioids soared in the towns, cities and counties that were saturated with billions of prescription pain pills from 2006 through 2012, according to government death data and a previously undisclosed database of opioid shipments made public this week.

The Post obtained and analyzed a previously unreleased database maintained by the Drug Enforcement Administration that tracks the path of every pain pill sold in the United States - by manufacturers and distributors to pharmacies in every town and city. That data was compared with individual death records from the Centers for Disease Control and Prevention, which were obtained and analyzed by The Post.

A map of the deaths and shipments reveals a virtual opioid belt of more than 90 counties stretching southwest from Webster County, West Virginia, through southern Virginia and ending in Monroe County, Kentucky.

This swath includes 18 of the top 20 counties ranked by per capita prescription opioid deaths nationwide and 12 of the top 20 counties for opioid pills distributed per capita. In the belt from 2006 through 2012, death rates from opioid abuse were 4.5 times the national average.

Nowhere is this more stark than in Norton, Virginia, a rural city of about 4,000 people, that lies in the eastern edge of the opioid belt.

In Norton, considered a county by the federal government, the per capita death rate from prescription opioid overdoses was 18 times the national rate. At the same time, drug companies shipped 306 pain pills per person per year, The Post analysis shows.

"That number blows me away," said Joseph Fawbush, Norton's mayor. "I believe the manufacturers misled the doctors. It is addictive, and they were telling the doctors it's not addictive."

Fawbush said opioids have devastated his town.

"Our jails are overflowing, a high percentage of children now have to be raised by their grandparents, and our court system and emergency services are strained," Fawbush said.

The analysis shows that McDowell County in the southern part of West Virginia along the Appalachian Mountains ranked second for rate of death from prescription opioids from 2006 through 2012.

In that period, the per capita death rate was 13 times higher than the national average in a county where drug companies shipped 96 pain pills per person per year. West Virginia also had the highest opioid death rate in the nation during this period.

Grappling with the epidemic, the McDowell County sheriff and others from the county came to Washington last year to meet with officials in Congress and the White House about the crisis and the lack of treatment resources.

"They have pumped a bunch of pills in here. It's such a bad situation," said Cecil Patterson, 64, a McDowell County commissioner and coal miner. "Every family has been affected by this. It's just overwhelming what's going on here. We are hard-working people. We'll survive this. But it has been tough. We've all had family members and friends we have lost to drugs."

The DEA database was released Monday by a judge in the largest civil action in U.S. history. About two dozen companies are being sued in federal court in Cleveland by nearly 2,000 cities, towns and counties.

"Now that we're seeing these things that we knew and couldn't prove, and now that we have these records, I think we should go after the living daylights of these people," Manchin said.

On Monday, U.S. District Judge Dan Polster lifted a protective order that had been concealing the database from the public. The database, the Automation of Reports and Consolidated Order System, known as ARCOS, contained seven years of data. The Post and HD Media, which publishes the Charleston Gazette-Mail in West Virginia, waged a year-long legal battle for access to the database and other documents. Last June, The Post and the Charleston Gazette-Mail asked Polster to lift the protective order covering the ARCOS database and the court filings. He declined, but the news organizations won access to the database on appeal.

The Post analysis shows that the volumes of the pills handled by the companies climbed as the epidemic surged, increasing 51 percent from 8.4 billion in 2006 to 12.6 billion in 2012. The overall number - 76 billion oxycodone and hydrocodone pills shipped over the seven years - eclipsed what was previously known about opioid distribution by orders of magnitude.

The prescription pill crisis was the first wave of an ongoing epidemic that hit rural areas particularly hard in West Virginia, Kentucky, South Carolina, Tennessee and Nevada, according to the database.

When the federal government began imposing hundreds of millions of dollars of fines on the largest drug distributors and pharmacies between 2008 and 2015, the supply began to tighten and pill addicts turned to heroin, triggering the second wave of the epidemic.

Increased heroin use ultimately led to the third wave of the epidemic, as Mexican drug cartels began blending their heroin with fentanyl, the deadly synthetic opioid shipped from China. Drug dealers in the United States also began selling fentanyl, leading to more than 67,000 overdose deaths from fentanyl from 2013 to 2017.

As the epidemic raged, local governments fought back. Norton and other communities filed lawsuits against the drug companies, alleging that opioids from the companies were destroying their towns. Some of the lawsuits allege the companies not only failed to report suspicious orders, but they also sought to maximize profits.

As hundreds of lawsuits began to pile up, many were consolidated into the one centralized case in U.S. District Court in Cleveland. The opioid litigation is now larger in scope than the tobacco litigation of the 1980s, which resulted in a $246 billion settlement over 25 years.

Keith Humphreys, a Stanford University professor who served as a drug policy adviser to the George W. Bush and Obama administrations, said the correlation of opioid deaths and pain pill distribution could be expected.

"These horrible death rates should not surprise anyone," Humphreys said. "The supply of drugs matters enormously no matter what else we try to do. When there's a flood of addictive drugs, lots of people end up being harmed."

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The Washington Post's Aaron Williams and Andrew Ba Tran contributed to this report.

Authors Information:

Sari Horwitz @sarihorwitz; Steven Rich @dataeditor; Scott Higham @ScottHigham1.