For decades, West Virginia has been ground zero for the opioid epidemic, as the opioid industry flooded the state with tens of millions of prescription painkillers that fueled overdose deaths and devastated families and communities. Now, the first federal trial among thousands of lawsuits in nationwide opioid litigation gets underway in Huntington County, West Virginia, which will test various legal theories that underpin the cases—and possibly lay the groundwork for settlements in other jurisdictions. The trial will see three of the country’s largest drug distributors—McKesson, AmerisourceBergen, and Cardinal Health—accused of allowing pills to flood into pharmacies largely unchecked. One county, for example, received more than 81 million prescription painkillers, or 91 pills per person per year. As a result, the state had the highest per-capital death rate from opioid overdoses in 2018, and 5 percent of West Virginia babies are born to mothers using opioids. The companies say there were too many steps between them and the opioid user to be held legally responsible for misuse, addiction and deaths. Over the past two decades, more than 400,000 Americans have died of opioid-related drug overdose, and millions more became addicted, setting the stage for the wave of lawsuits that also accuse opioid manufacturers and retail pharmacies of being responsible for the crisis. The West Virginia case goes ahead even as settlement talks continue in other jurisdictions with drug distributors, and opioid makers including Purdue Pharma, amid disputes between the companies and states’ attorneys general over the terms of the deal.