“Areas in this country hardest hit by the prescription opioid crisis were the same areas targeted by drug companies marketing opioids,” said Scott Hadland, a pediatrician and researcher at the Grayken Center who was the lead author of the study.

Cabell County, West Virginia, for example, received 32 times more dollars in prescription opioid marketing than the national average. Opioid manufacturers spent $11,676 on marketing per every thousand residents living in the region at the foothills of the Appalachians.

That money had an impact, Hadland said. Cabell County saw the most prescription opioid overdose deaths in the U.S. during the months surveyed.

Across the state line, doctors in Salem City and Winchester City, Virginia, experienced the most frequent marketing interactions. Frequency of marketing had a stronger correlation to prescription opioid overdose deaths than the amount spent, the study found.

“These small, frequent interactions are really the potential driver of this public health crisis — and yet it's legal,” Hadland said. “There needs to be tighter regulation.” Under Scrutiny

The study analyzed county-level marketing data from the Centers for Medicare and Medicaid Services and compared it with overdose mortality data from the Centers for Disease Control and Prevention from the following year. While researchers examined the outcomes of deaths related to prescription opioid overdoses, many of the fatalities also involved heroin, fentanyl and other illicit opioids.

Manufacturers have come under scrutiny for their marketing tactics amid the national opioid overdose epidemic, which was tied to about 50,000 deaths in 2017. More than 1,500 suits have since been filed by state attorney generals, cities and counties against companies including Purdue Pharma LP, Endo International Plc and Johnson & Johnson. The governments contend the companies downplayed painkillers' health risks and oversold their benefits through hyper-aggressive marketing campaigns.

Lawyers for state attorneys general and local governments have been in settlement talks for more than a year with makers and distributors of opioids, without reaching a deal.

A handful of manufacturers have voluntarily halted marketing their opioids since the study was conducted. Endo stopped promoting pain products to health-care professionals and eliminated its 375-person salesforce in December 2016, while Purdue ended promotion of opioids to physicians in February 2018. Legal experts have said that halting marketing could build goodwill with judges in ongoing litigation.

“We recognize we have a role to play to help address this public health crisis and have taken action to do so,” said Purdue spokesman Robert Josephson in an emailed statement. He noted the company has also distributed CDC guidelines to opioid prescribers and funded efforts to make the opioid overdose antidote naloxone more accessible to the public.

Read more: 

• New lawsuit unveils scope of Purdue's 'extraordinary efforts' to push opioids
• The opioid epidemic claims its first corporate victim
• Addressing opioids in the workplace: Why altering your benefits isn't enough

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