Baltimore’s trial against opioid distributors ended in a major victory for the city Tuesday. The drug companies, McKesson and AmerisourceBergen, will have to pay more than $266 million in damages to the city if the verdict survives an appeal. Here’s how we got here and what the next steps are:

What happened?

Baltimore sued a group of pharmaceutical giants in 2018, claiming the companies contributed to a devastating opioid overdose epidemic that has killed thousands of city residents. The lawsuit eventually named companies at every level of the opioid supply chain, including the OxyContin maker Purdue Pharma, Johnson & Johnson, Walgreens and CVS.

The lawsuit claimed that drug companies ignored their legal and moral obligations when they pushed to increase sales of opioids with little concern for the drugs’ potential to cause addiction. Long known as the nation’s heroin capital, Baltimore had made progress in reducing opioid overdoses in the early 2000s, but alleged in the lawsuit that the influx of easily accessible prescription opioids reversed those gains.

As the case neared a trial, most of the defendants chose to settle. The city held out longer than other communities in an effort to win more money for opioid remediation. In all, Baltimore won over $400 million in settlement money before setting foot in a courtroom.

The trial ended Tuesday with a $266 million verdict against the two companies that didn’t settle, McKesson and AmerisourceBergen. A jury of six Baltimore residents found the companies liable for contributing to a public nuisance stemming from the misuse of prescription opioids.

Did the city’s legal strategy work?

Big time. Even before the trial, Baltimore won more in settlements than the entire state of Maryland will receive as part of a massive “global settlement” with Johnson & Johnson and the opioid distributors McKesson, AmerisourceBergen and Cardinal Health. The statewide settlement will be paid out over 18 years.

Baltimore declined to participate in the global settlement in hopes of winning more money. It was a risky move that paid off. With Tuesday’s verdict, the city’s total winnings topped $668.5 million.

What happens now?

First, there will be an “abatement” phase of the opioid trial, which will begin Dec. 11. Baltimore will ask for a huge sum of money — between $8 billion and $11 billion — to remediate the effects of the opioid crisis on the city.

The abatement portion will be decided by a judge instead of a jury. Baltimore City Circuit Judge Lawrence Fletcher-Hill, who oversaw the jury trial, will decide how much money the drug companies have to pay in abatement. Fletcher-Hill has appeared skeptical of the city’s arguments during the trial, so it’s not clear how he will rule. But the possibility of an even bigger financial loss could push McKesson and AmerisourceBergen to settle.

The drug companies have already said they are evaluating the verdict and may appeal. First, they will file motions challenging the verdict. If those don’t succeed, they will appeal to Maryland’s higher courts. Some opioid verdicts in other states have been thrown out on appeal.

Where will the money go?

Baltimore Mayor Brandon Scott previously laid out a multiyear plan for spending the opioid money. Some of the money has already been allocated to community organizations and substance use treatment programs.

Much of the winnings will be placed in an investment trust and doled out over a period of years. A “Restitution Advisory Board” will make recommendations for spending the money, and those recommendations will be reviewed by an “Overdose Cabinet” before the mayor makes the final call.

City agencies, health care providers and other organizations will be able to apply for money from the trust fund.

The city’s outside law firm, Susman Godfrey, will also receive a large chunk of the money. The city has declined to provide its agreement with the firm, but has said Susman Godfrey will receive about a third of the money the city wins. That’s standard in cases taken on contingency, where the law firm agrees not to take a cut unless its client wins money.

Susman Godfrey will also be reimbursed for costs it fronted during the six years of litigation.

How bad is Baltimore’s opioid crisis?

Very bad. A Baltimore Banner/New York Times investigation found that Baltimore’s overdose rate exceeded that of any other major American city from 2018 to 2022. Nearly 6,000 people died of overdoses in six years.

The death rate skyrocketed with the introduction of fentanyl, a potent synthetic opioid, into the illegal drug supply. In its lawsuit, Baltimore argued that people who became addicted to prescription opioids transitioned to illegal street drugs, like heroin and fentanyl, after legal painkillers became harder to find.

Opioids flooded the United States in the 2000s as doctors, encouraged by pharmaceutical companies, began prescribing larger amounts of the medications to more people experiencing chronic pain. More than half a billion opioid pills were shipped to Baltimore City and county during the height of prescribing.

What was the city’s argument?

The city accused drug companies of inundating the area with painkillers that they knew were likely not medically necessary. In the trial that ended Tuesday, Baltimore claimed the drug distributors ignored clear “red flags” at pharmacies that were ordering massive shipments of opioids.

Among those pharmacies was Dundalk’s Drug City, which received nearly 20 million opioids between 2006 and 2019, and was at one point McKesson’s top buyer of oxycodone in the nation among independent pharmacies.

Though federal regulations required drug manufacturers and distributors to report suspicious orders of controlled substances, the city claimed that McKesson and AmerisourceBergen ignored that responsibility and went years without reporting a single suspicious order in Baltimore.

How did the drug companies respond?

McKesson and AmerisourceBergen disputed the city’s claims and argued that they simply shipped legal painkillers to registered pharmacies as permitted under the law. The orders were made to fill demand from patients who received prescriptions from their doctors, the companies said.

The lawyers for the companies also pointed blame at other parties, including gangs and drug cartels that ship fentanyl into the United States. Any diversion of the legal opioids that McKesson and AmerisourceBergen shipped to Baltimore took place after those drugs left the pharmacies, the companies said.

Jurors disagreed, handing a resounding victory to the city after less than two days of deliberation.