The Cost of ‘Pill Culture’ and the Opioid Epidemic in Dallas County

JoDee Neil is an attorney with Simon Greenstone Panatier, where she manages Dallas County’s opioid epidemic litigation against major pharmaceutical companies and distributors.

Last month, Dallas County signed off on a $2.3 million settlement with Johnson & Johnson subsidiary Janssen as part of a larger $290 million settlement Texas made with the pharmaceutical manufacturer, which has been sued by hundreds of state and local governments across the country. (The various manufacturers and distributors being sued have all denied responsibility for causing the opioid crisis.)

Dallas County, which outside of its direct payment will be able to access millions of settlement dollars in a regional fund, intends to spend that money on fighting the epidemic itself. “Hopefully that fund will just get bigger and bigger and we can fund opioid divert courts, drug courts,” Neil says. “Maybe additional equipment and investigators for the medical examiner. Obviously we need tons of rescue drugs and a whole lot of education.”

Much of Neil’s work has involved collecting data on the toll opioid addiction has taken in Dallas. There are the hundreds of overdose deaths every year, the swelling jail population, the burden on public health care.

“We’ve been asked, ‘How are we able to link conduct to outcomes? Can you prove one person was hurt from one shipment [of opioids]?’” she says. “We’ve been able to link all these things to prove stuff that no one ever thought we could prove. There’s a paper trail.”

Dallas County is pushing forward with its lawsuit against the other pharmaceutical companies—a trial date has been set for February—but Neil’s work is already paying dividends. There is a rare bipartisan consensus on holding pharmaceutical companies accountable for their role in the crisis, and a growing recognition that anyone, anywhere, can suffer from drug addiction.

This is especially true in a place like Dallas, which has what Neil calls a “pill culture” that makes it easy for people from all walks of life to fall into drug abuse. “That’s what makes this a public health issue, not a criminal justice issue,” she says. “There are so many people that have access to these drugs specifically because they’re just floating around in everyone’s medicine cabinet.”

I spoke with Neil on a Zoom call. This interview was condensed and edited for length and clarity.



Just to zoom out for a second, why are so many cities and counties across the country suing opioid manufacturers? How do you make the case that these pharmaceutical companies are responsible for the opioid epidemic?

Controlled prescription drugs were used, around 1995, in a very limited capacity. They were prescribed by palliative care doctors, oncologists, surgeons. But through a targeted effort by Purdue—which the other manufacturers were aware of and went along with because it’s a very competitive industry—the practice in medicine was changed, by deliberate design. Specific high-dose opioids were invented to treat the symptoms of pain, not the underlying injury. They were invented to treat withdrawal vs. acute pain. They were approved to be prescribed for moderate pain, and non-cancer pain. The manufacturers and the distributors went along with this scheme to make money. 

The manufacturers made the drugs. But the distributors had a legal duty [to act] when they saw what was happening. If you have a pharmacy that was ordering maybe one box of hydrocodone fives (5-mg strength pills) for the past decade and then all of a sudden they start ordering ten boxes of hydrocodone tens (10-mg strength pills), that’s a big adjustment. The distributors had the responsibility under the Controlled Substances Act to stop this from happening. We trusted them with this closed system of distribution, and they betrayed our trust.

How has the opioid epidemic unfolded here in Dallas County? I think the public image of this crisis is often of devastation in the Rust Belt, or Appalachia, but obviously this is a national problem that is felt here in Dallas. What does that look like?

The Dallas County case is a lot different than Appalachia, than what you would see on [new television show about the opioid crisis] Dopesick or one of the shows about West Virginia. Dallas is a very strong hydrocodone market. The data has us in the top 5 for hydrocodone [use] in the country. If you look at the publicly available sources, you’ll see that—only for hydrocodone and oxycodone—there were 606 million dosage units that came into Dallas County between 2006 and 2014. And that doesn’t count the syrups, the powders, Tramadol. There’s a lot that’s excluded. What we’ve discovered is that the drug companies knew that we were a habitual market. We were not a hard sell. We were already taking very large volumes of hydrocodone. I call them the Advil of Texas. We have a pill culture. That’s something that I’ve had to reconcile with my upbringing, growing up here. It’s so common, if you go to a party and you’re like ‘Oh, my back hurts.’ Someone will have a hydrocodone.

You’re not having small populations of miners—just comparing Dallas to Dopesick—or this very concentrated population that are only taking high-dose opioids. You have large populations that have so many pills available to them, opioids being one of many. What we’ve found is that it’s just created an underlying dependence on opioid drugs that has seeped into so many aspects of the county’s functioning. You go to any county meeting except maybe road and bridge: behavioral health, the jail population, criminal justice. The drug problem in Dallas is epic, and not in a good way.

I’ve heard [Dallas County Judge] Clay Jenkins talk about that, how drug addiction takes its toll on not just addicts themselves but on public resources: public safety, health care, much more than what you might typically identify as a “drug issue.”

It’s true, and Dallas is a distribution hub for all three of the major distributors: McKesson, AmersourceBergen, and Cardinal. We’ve got lots of highways here, the airports. It’s a prime location for access to drugs. Experts say people take what’s available. You get people with a lot of co-occurring issues here. The trick is drilling down to see what role the opioids played in it. That’s what we’ve done with the death data, with the criminal data. And there’s a high mortality here for opioid overdose. It’s varied in the past 10 years, between three and 400 per year. At least every other day on average, there’s an opioid death.

You’ve said that Dallas County’s case served as a bellwether, or kind of test case, for many of the plaintiffs in Texas suing Johnson and Johnson and other pharmaceutical companies. What made Dallas County so compelling as a bellwether?

Dallas County is particularly well-suited to be a bellwether because Dallas County has a lot of very good data. Our medical examiner kept great records. We pulled every autopsy going back to 1990. We hired experts—statisticians and health economists—to look at that data and draw some conclusions. The criminal data is good. We pulled every single indictment that we could lay our hands on. We have a case that’s based on the actual harm that’s happened in Dallas County vs. just this theoretical idea of a public nuisance. [The Oklahoma Supreme Court recently threw out a $465 million ruling against J&J in which the plaintiffs argued that the drug industry’s opioid marketing constituted a “public nuisance.”]

What’s the distinction between the “past damages” case you’re making and the “public nuisance” cases that have been thrown out in Oklahoma?

So public nuisance is a cause of action that’s only available to government plaintiffs, and public nuisance has a very specific remedy, which is abatement. It’s a very general kind of overarching cause of action. Basically, there’s been harm that affects people all over the country, and it needs to be fixed. Obviously, it’s someone’s fault, too. Well, we drilled down even further and we said yes, of course there’s a harm to the county, but this is what it looks like. This is how many indictments we were able to locate—what percentage were from this, that, or some other drug. We’ve been asked, ‘How are we able to link conduct to outcomes? Can you prove one person was hurt from one shipment [of opioids]?’ We’ve been able to link all these things to prove stuff that no one ever thought we could prove. There’s a paper trail.

What we’ve discovered is that the drug companies knew that [Dallas County was] a habitual market. We were not a hard sell.

What happens with the money from the recent settlement with J&J? How do you ensure that settlement money gets fairly distributed?

The breakdown is that 15 percent goes to the state and 15 percent goes to the political subdivisions, of which Dallas County is one. And then 70 percent goes to an abatement fund that is overseen by the [Texas] Opioid Council. Subdivisions can fill out an application explaining what they want to do with the money, and the council will approve it, and you’re going to be able to fund your program. You know, ‘Hey we need a Naloxone [medicine used to reverse opioid overdoses] stash for the county. We can go to the regional fund.’ Hopefully that fund will just get bigger and bigger and we can fund opioid divert courts, drug courts. Maybe additional equipment and investigators for the medical examiner. Obviously we need tons of rescue drugs and a whole lot of education.

Can you tell me a little about what working on a case like this has meant to you on a personal level?

In December, it’ll be three years where this is all I do for a living. In 2018, Jeffrey Simon [founding partner of Simon Greenstone Panatier, where Neil works] gave a presentation on what we knew at that time of the opioid epidemic. And I had seen chit chat about the epidemic. But I had also grown up in pill culture and around addicts, to some extent. Even though, you know, I grew up in an upper middle class family. My dad was a trial lawyer too. And I just heard in my head ‘addicts, blah blah blah.’ But when Jeffrey gave this PowerPoint, I just felt so much forgiveness in a moment, especially for my own mother, who died from an overdose in 2010. 

Part of what I have done in this case is show experts her death certificate. Even though it was a drug overdose, that was listed No. 3 on the death certificate, and it was called a natural death by the doctor in the hospital. So her overdose didn’t count toward CDC mortality data or suicide numbers or anything. It was just like she never existed. Growing up in the pill culture and around her addiction, I naturally had a lot of anger. This lawsuit is really helping to change the conversation where addicts are concerned. So much of the judgment and anger I had toward my mother has gone away because of the forgiveness that I found in the truth. That’s been the most important part of this litigation to me, is changing the way I think about addicts, forgiving myself and the addict for everything that’s happened, and then figuring out how we’re going to change the conversation going forward.

What else should people know about all of this?

My four-alarm fire right now is fentanyl. There has been a sharp uptick in fentanyl in the past three years. The supply of prescription opioids has shifted downward, just enough to create a market for fake pills. We’re seeing fentanyl showing up in places we never thought it would, in other recreational drugs. With a pill culture like we have in Dallas, I see a real danger. Recreational drug use is extremely common and to act like it’s not is just not connected to reality. 

It seems in recent years the conversation really has changed, and there’s a growing acknowledgment of how anyone can become a drug addict.

That’s what makes this a public health issue, not a criminal justice issue. There are so many people that have access to these drugs specifically because they’re just floating around in everyone’s medicine cabinet.