Protesters leave pill bottles outside the headquarters of Purdue Pharma in Stamford, Conn., on Aug. 17. (Jessica Hill/AP)

THE PHARMACEUTICAL industry’s direct marketing to physicans, through free samples, meals, consulting and paid speaking engagements, has long been controversial. Government regulations emphasize disclosure of doctor-industry relationships; the industry has its own voluntary code of conduct. At its best, drug company marketing can enhance the medical community’s knowledge of new therapies. At other times, it can result in overpromotion of risky products.

Two newly released documents illustrate the latter point. First, a study of overdose deaths due to prescription opioids between 2014 and 2016 shows an association between such deaths and direct-to-physician marketing. Specifically, the U.S. counties with the highest rate of marketing interactions with physicians also had the highest rates of prescription-opioid-related fatal overdoses, according to the study, which appeared in the medical journal JAMA Open Network. A fifth of all family physicians received at least some emolument from opioid-makers during the study period.

Second, the attorney general of Massachusetts, Maura Healey, has filed a lawsuit in state court detailing highly aggressive marketing tactics by Purdue Pharma, makers of OxyContin. According to the lawsuit, the privately held company’s owners, the Sackler family, directed sales personnel to focus on doctors known to prescribe the opioid in high volumes, targeting them with repeat sales calls in which they were urged to prescribe even more frequently and in increasing doses. Confronted in 2001 with early reports tying OxyContin to an addiction epidemic, Richard Sackler, then the company president, urged his staff in an email “to hammer on the abusers in every way possible. They are the culprits and the problem. They are reckless criminals,” according to the lawsuit, which drew on internal Purdue documents produced for a separate lawsuit in Ohio federal court.

The Massachusetts lawsuit charges Purdue with continuing to market OxyContin dishonestly for a decade after it pleaded guilty in 2007 to federal deceptive-marketing charges and paid $600 million in fines. Purdue, which ended direct-to-physician marketing in February 2018, denied the accusations and called the lawsuit a “rush to vilify a single manufacturer.” Purdue was released from federal supervision in 2013 after completing terms of its plea agreement.

To be sure, the opioid epidemic now is driven more by fentanyl and heroin than prescription drugs with which it began. As of 2017, opioid prescribing was down 28 percent since it peaked at 81.3 prescriptions per year per every 100 Americans in 2012. These drugs are nevertheless far more commonly prescribed than they were two decades ago and were involved in 17,000 overdose deaths in 2017, more than 35 percent of all such fatalities. There are still regional discrepancies in prescribing rates that cannot be entirely explained by health conditions, according to the Centers for Disease Control and Prevention.

Although the JAMA Open Network study found an association between heavy marketing and opioid deaths — not causation — it supports the idea that further progress against the opioid epidemic may require more marketing restraint. Certainly the study was wise to note that policymakers should “consider limiting the extent to which pharmaceutical companies may contribute to inappropriate opioid prescribing while balancing the need for access to opioids for patients who need them.”