Major pharmaceutical companies heavily influenced doctors to prescribe high rates of opioid medications with lavish spending, new research suggests.

Doctors, who received paid speaking gigs, free lunches and branded merchandise from drug makers, were linked to much high rates of opioid prescriptions, a research letter published Monday in the the Journal of the American Medical Associations JAMA Internal Medicine found. In 2014, every free meal given to a doctor from pharmaceutical companies resulted in a spike of opioid prescriptions from the doctor, the study authors, lead by Dr. Scott Hadland of the Boston University School of Medicine, concluded, according to NBC News.

Insys Therapeutics, a fentanyl manufacturer currently mired in federal investigation, spent the most of any drug maker on various payments to physicians. Opioid prescriptions rose an average of nine percent when a doctor received payments from the pharmaceutical industry, the researchers estimated.

“Amidst national efforts to curb the overprescribing of opioids, our findings suggest that manufacturers should consider a voluntary decrease or complete cessation of marketing to physicians,” Hadland said, according to NBC News. “Federal and state governments should also consider legal limits on the number and amount of payments.”

OxyContin maker Purdue Pharma, which often faces the brunt of criticism over the opioid epidemic, ended their marketing practice of promoting painkillers to health care professionals in February.

Outside of Insys, however, the biggest spenders on promotion to doctors are Teva Pharmaceuticals and Johnson & Johnsons Janssen Pharmaceuticals, according to the researchers.

Insys, which produces a fentanyl patch, Subsys, for cancer patients, is currently facing lawsuits in multiple states for illegally bribing doctors to unnecessarily push the dangerous medication. Seven former Insys executives and managers are battling allegations in Boston. John Kapoor, the billionaire founder of Insys, is also under investigation for allegedly personally directing the companys bribery schemes.

Insys defrauded insurance companies by giving payouts to doctors who overprescribed Subsys or prescribed it for unapproved conditions, including through fees for fake speaking engagements, the lawsuits claim.

Fentanyl, a synthetic opioid roughly 50 to 100 times more powerful than morphine, overtook heroin as the deadliest substance in the U.S. in 2016, claiming 19,413 lives in 2017, according to data from the Centers for Disease Control and Prevention.

Drug overdoses are now the leading cause of accidental death for Americans under age 50, killing more than 64,000 people in 2016. Opioid overdoses made up a staggering 66 percent of all drug overdose deaths in 2016, surpassing the annual number of lives lost to breast cancer.

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