More than half a billion opioid pills permeated the Baltimore area between 2006 and 2019 as pharmaceutical companies targeted doctors with aggressive marketing campaigns, underplayed their products’ addictiveness and failed to block suspiciously large orders of painkillers, according to a trove of court records made public as part of the city’s lawsuit against some of America’s top drug companies.

The resulting glut of opioids reversed hard-won reductions in heroin overdose deaths and created a new generation of opioid users who overwhelmed the city’s resources, the lawsuit claims. Overdose deaths in the city began climbing to devastating new highs, quadrupling between 2011 and 2017, for example.

The Baltimore Sun reviewed thousands of pages of court records and used a massive database of drug sales transactions compiled by The Washington Post to assess how prescription opioids and the companies that peddled them contributed to the crisis.

The evidence reveals an untold story: Millions upon millions of legal opioids inundated the city and Baltimore County as pharmaceutical sales representatives singled out the highest-prescribing doctors for advertising, cracked jokes about the growing addiction crisis and minimized the potential for addiction.

Sales staff from Janssen, a Johnson & Johnson subsidiary, created a “March Madness” style bracket using Baltimore physicians instead of basketball teams for a campaign to boost opioid prescribing.

Doctors who prescribed large quantities of opioids were nicknamed “whales” that the sales team wanted to “own.” Some physicians targeted for intense opioid marketing would go on to be criminally charged.

The owner of a Baltimore County pharmacy that dispensed nearly 20 million pain pills over 14 years testified that a representative from the major drug distributor McKesson did not seem concerned about the diversion of opioids.

“Absolutely not,” the owner said during a deposition in November. “The salesman congratulated me.”

The drug company defendants have asked a judge to throw out the lawsuit. A hearing on those motions for summary judgment is scheduled for Monday. If the lawsuit survives, a 12-week trial is set to begin in September. The companies argue that they followed the law, providing FDA-approved opioids to licensed pharmacies after doctors wrote prescriptions for their patients. They also fault the city for not identifying specific orders of opioids that led to harm.

“Manufacturers lack control after the medications are sold to distributors; distributors lack control after the medications are distributed to pharmacies and other dispensers; and all of the defendants lack control after the medications are dispensed to patients,” the companies’ attorneys wrote in a joint filing.

In all, more than 250 million pain pills entered Baltimore City from 2006 to 2019, and more than 400 million came to Baltimore County. The data, filtered by The Post, includes only oxycodone and hydrocodone pills, which made up most of the market — or roughly three-quarters of all dosage units in Maryland for the time period.

Baltimore Mayor Brandon Scott described the lawsuit as an effort to get justice for Baltimoreans who suffered because of the city’s opioid overdose epidemic.

“Baltimore had made incredible progress in addressing heroin addiction in the mid-2000s, but defendants in this case — some of the largest, most powerful pharmaceutical companies in the world — flooded our city with millions of pills in pursuit of profits, with no regard for the lives they would ultimately destroy,” Scott said in a statement.

“When we look at the status of our effort to combat opioids today, we cannot overlook the devastating impact their actions had. They need to be held accountable, and they need to be financially responsible for addressing their destruction.”

The city’s lawsuit names a number of major companies, including the OxyContin maker Purdue Pharma. Some companies, including Purdue, filed for bankruptcy, removing themselves from the litigation. Claims against CVS, Walgreens, Johnson & Johnson, Cardinal Health, AmerisourceBergen (now known as Cencora), Teva and McKesson remain in Baltimore City Circuit Court.

Teva and Cardinal Health did not respond to requests for comment. In a statement, Cencora said it is “looking forward to sharing with the court the facts about our role in the supply chain and our long-standing commitment to fulfilling our regulatory responsibilities and doing our part to combat the opioid crisis.”

“Cencora does not determine the supply of the medications it distributes, nor do we impact demand for those medications,” the company said. “The DEA has always been responsible for setting the supply of opioid medications through its use of annual quotas, and demand is driven by the licensed physicians who write prescriptions based on their independent medical judgment. Cencora had no role in working with the DEA to set quotas, nor did we interact with physicians or patients to recommend particular medications.”

Marketing: Opioid consumption in the United States remained fairly flat for decades until the 1990s, when pharmaceutical companies and a growing pain advocacy movement began pushing for broader use of the drugs. Once reserved to treat the most serious pain, opioids were hailed as a long-term solution for chronic pain, even without strong scientific evidence that the benefits outweighed the risks.

Court records show pharmaceutical companies followed the same opioid playbook in Baltimore as they did elsewhere, aggressively marketing opioids to doctors while downplaying the chances of opioid dependence and addiction.

Cephalon, a pharmaceutical company later acquired by Teva, promoted a fentanyl lollipop called Actiq for a variety of uses, even though the drug had been approved by the FDA only for cancer patients with severe pain who were tolerant to opioids.

The company pleaded guilty in 2008 to marketing drugs, including Actiq, for off-label uses.

“Using the mantra ‘pain is pain,’ Cephalon instructed the Actiq sales representatives to focus on physicians other than oncologists, including general practitioners, and to promote this drug for many uses other than breakthrough cancer pain,” the U.S. Department of Justice wrote when it announced the plea and $425 million settlement.

Internally, Cephalon’s Baltimore sales manager joked in an email to colleagues about an article that warned Actiq was being sold illegally under the nickname “perc-a-pop” and compared doctors with concerns about drug abuse to Chicken Little, according to the court filings.

Pharmaceutical sales reps called Baltimore physicians hundreds of times, targeting what Janssen’s sales reps called “whales” — the highest prescribers — in hopes of selling more.

The companies also paid local doctors to give presentations on their products.

One doctor who received tens of thousands of dollars in speaking fees was Howard Hoffberg, the associate medical director at the Rosen-Hoffberg Rehabilitation and Pain Management Practice in Owings Mills and Towson.

Both Hoffberg and the clinic’s medical director, Norman Rosen, faced criminal charges stemming from the practice.

Rosen pleaded guilty in early 2023 to conspiracy to distribute oxycodone and received four months of home detention. According to his plea agreement, Rosen felt that “the patient was always right” and prescribed opioids in large quantities even to people who showed clear signs of abusing street drugs. When Hoffberg turned away patients for problematic behavior, Rosen often overruled him and continued treating the patients at another clinic location.

Hoffberg pleaded guilty to accepting $66,000 in kickbacks from Insys Therapeutics Inc., a drugmaker that produced an opioid called Subsys. Hoffberg received “honoraria” for participating in Insys’ speaker program, money the feds described as “bribes” to prescribe Subsys to patients. (Insys filed for bankruptcy in 2019.) He was sentenced to eight months in prison.

Before the criminal charges, the Rosen-Hoffberg clinic was a frequent target of opioid marketing by pharmaceutical sales reps, receiving hundreds of calls and visits. Hoffberg also gave paid talks for Purdue Pharma and Cephalon, according to a declaration he provided as part of the city’s lawsuit.

The clinic was widely known to have problems; patients often nodded off, experienced behavioral problems or showed other signs of opioid use disorder in the lobby of the busy practice, according to Hoffberg’s declaration.

Sales representatives who called and visited were “assertive with me and my staff and urged us to promote more and more of their opioid products,” Hoffberg wrote.

“In my experience, all these companies cared about was promoting their opioid products and making money, and they never expressed any concern about me or my practice prescribing opioids and preventing diversion,” wrote Hoffberg.

Asked for comment, Hoffberg emphasized that he was not convicted of improperly prescribing painkillers and that his practice offered treatment for opioid use disorder.

“I was never accused of illegitimately prescribing opioids,” he said. “They were always prescribed in conjunction with multidisciplinary care including those that I treated for opioid use disorder.”

Chronic pain patients have suffered because of lawsuits like Baltimore’s, he added, because doctors are now less willing to prescribe opioids due to stigma.

“Many chronic pain patients, including those at my practice, felt victimized as a result of these litigation proceedings,” he said.

Johnson & Johnson also sought to increase opioid prescribing more broadly through “unbranded marketing,” paying doctors and organizations — including the Baltimore-based American Pain Foundation — to promote opioids under the guise of patient advocacy. The foundation closed in 2012 after a ProPublica investigation revealed its extensive financial ties to the pharmaceutical industry.

In a statement, a Johnson & Johnson spokesperson said the company deeply sympathizes with those affected by opioid abuse and addiction.

“We will challenge the City’s claims — which have no basis in the facts or the law — and the evidence will show that Janssen did everything a responsible manufacturer of these important prescription pain medicines should do,” the statement continued.

Distribution: As opioid sales exploded across the nation and in Baltimore, the companies distributing all those pills were supposed to report suspicious orders to the Drug Enforcement Administration.

They didn’t, the city’s lawsuit argues.

Major distributors who sent millions of opioids into the city went years without reporting a single suspicious order — or never reported any at all, according to Gary Tuggle, a DEA veteran who briefly served in 2019 as an interim commissioner of the Baltimore Police Department.

At the city’s request, Tuggle used federal data to evaluate opioid orders sent to Baltimore city and county from 2006 through 2019. He calculated that between 440,000 and 645,000 suspicious orders came to the area in those years, sent by just three distributors: AmerisourceBergen, Cardinal Health and McKesson. Tuggle included Baltimore County because city residents often use pharmacies there, according to his report.

“The defendants did not just fail to monitor, report, and stop suspicious opioid orders in Baltimore,” Tuggle wrote. “The defendants ran national suspicious order monitoring programs, and their programs were inadequate everywhere. The result was that diversion of opioids occurred around the country.”

The defendants dispute Tuggle’s findings and challenged his conclusions with their own expert reports. Tuggle and the city’s other experts declined to comment for this story because of the pending litigation.

Distributors also helped pharmacies avoid triggering opioid thresholds by warning them when they neared their limits for orders, coaching them to place small daily orders for opioids instead of large ones that could set off red flags, and raising thresholds for any reason, including “increased business,” the court filings show.

As millions of opioids spread across the country, some employees began raising concerns internally.

Walgreens pharmacists in Baltimore repeatedly asked questions about the Rosen-Hoffberg pain clinic, court records show.

“To be honest, I do not feel very comfortable with my license on the line filling for that clinic,” one wrote, according to internal emails.

In response, Walgreens had a staff doctor call the clinic. In a subsequent email, she wrote: “Great discussion with the Rosen-Hoffberg docs — we should fill their scripts!”

That was in 2016. In 2018, after the Maryland Board of Physicians reprimanded Rosen, court records show another Walgreens pharmacist emailed with concerns about filling the clinic’s prescriptions. The DEA raided the clinic soon after.

A Walgreens spokesperson declined to comment, citing the litigation.

Other distributors faced enforcement actions related to their opioid sales in Baltimore. CVS paid $8 million in 2016 to settle with the U.S. Attorney’s Office in Maryland for dispensing controlled substances at its Maryland pharmacies, including oxycodone, fentanyl and hydrocodone, “in a manner not fully consistent with their compliance obligations” under the Controlled Substances Act.

In an email, a CVS spokesman noted that the 2016 settlement related to the company’s pharmacies, not the distribution operation that the city’s claim targets. CVS’ distribution centers shipped less than 1% of the prescription opioids at issue in the lawsuit, the spokesman said.

“We strongly disagree with the allegations in this lawsuit and continue to vigorously defend against them,” the spokesman said.

The distributor McKesson entered into a $13 million settlement with the DEA in 2008 for regulatory problems, including selling 3 million hydrocodone doses to Baltimore’s Newcare pharmacy without reporting the sales as suspicious. The pharmacy’s owners were arrested in 2006 and received five years in prison each for illegally selling 10 million hydrocodone pills over the internet.

McKesson was by far the largest distributor of opioids to Baltimore City between 2006 and 2019, according to The Post’s database, responsible for over a third of the pills distributed.

The company settled with the DEA again in 2017, this time for $150 million. McKesson agreed that it failed to maintain effective protections against the diversion of controlled substances at several distribution centers, including one in Landover.

McKesson did not respond to a request for comment.

A ‘calculated gamble’: The city and the opioid defendants offer two very different stories of Baltimore’s opioid crisis.

Baltimore had a well-known heroin problem for decades before prescription opioids became a major factor. But the city achieved declines in heroin overdoses between 1999 and 2009, a trend scholars attributed to the expansion of medication-assisted treatment for opioid use disorder.

By making an enormous supply of prescription opioids easily accessible, the city claims, opioid manufacturers and distributors reversed any progress Baltimore had made in addressing overdoses and made existing problems far worse.

The oversupply introduced a new cohort to opioids, either through legal prescriptions or “medicine cabinet” diversion of pills. When opioid users turned from prescription pills to cheaper and more deadly street drugs, the city argues, overdoses skyrocketed.

The defendants say their opioids had little effect on a city with a serious illicit drug problem. In court filings, the companies blamed illegal drug trade and raised questions about opioids taken from pharmacies during the 2015 unrest following Freddie Gray’s death from injuries suffered while in police custody and about officers who were investigated for stealing drugs.

“As for illicit, non-prescription opioids such as heroin, the record is replete with evidence that Baltimore City was plagued by these illegal drugs long before the rise in opioid prescribing, and that they have at all times been distributed by illegal drug trafficking organizations, not distributors,” the companies wrote in a joint filing.

The truth may be somewhere in between, said Dr. Eric Weintraub, the head of the University of Maryland School of Medicine’s Division of Addiction Research and Treatment. Baltimore had a preexisting heroin problem, but in recent years, many people began using opioids because they had access to prescription pain medicines, he said.

“It’s hard to know exactly what is the cause of the increase, but it’s clear that many individuals became dependent on illicit opioids by first using prescription pain medication,” said Weintraub, who is not involved in the city’s lawsuit.

Brendan Saloner, a professor and addiction researcher at the Johns Hopkins Bloomberg School of Public Health, estimated in an expert report for the city’s lawsuit that more than 80% of Baltimore’s opioid use disorder cases between 2010 and 2021 began with prescription opioids, not heroin. Saloner declined to comment for this story, citing the pending litigation.

The causes of Baltimore’s overdose crisis are difficult to untangle, Weintraub said. A massive supply of prescription opioids, followed by a rise in the potent synthetic opioid fentanyl, made for a deadly combination.

“I don’t think you can say that what happened in Baltimore prior to the prescription pain issue is irrelevant, but I also think it was exacerbated and compounded significantly by the prescription problem,” Weintraub said.

Baltimore’s opioid problem will be expensive to remediate, no matter the cause. The city is seeking about $11.5 billion in damages. The money would go toward a comprehensive opioid abatement program.

The lawsuit is especially significant because Baltimore rejected a $400 million opioid settlement reached by the Maryland Attorney General’s Office two years ago. Instead of joining thousands of state and local jurisdictions in the global settlement, Baltimore decided to go it alone in hopes of winning a larger sum. (A $45 million settlement announced in June with the opioid maker Allergan suggests the approach may pay off.)

The strategy comes with risk, said Bruce Poole, a Hagerstown attorney who helped handle opioid lawsuits for several Western Maryland jurisdictions.

“In this case, the city looked at their problem and took a very calculated gamble and decided to go for it,” Poole said.

If the lawsuit survives the summary judgment stage, the city could win an enormous amount at trial. If the city succeeds on its motions ahead of the trial, a jury of Baltimoreans will get to decide the outcome of the case and the defendants will have to contend with what Poole calls the “drive-by proof”: the devastation wrought by the opioid crisis that is plainly visible on the streets of Baltimore.

“If you’re a juror, I don’t know how you don’t know that this problem exists on a personal experience level,” Poole said. “You may not have had anything to do with opioids, and maybe your family hasn’t, but you still see it in the communities.”

Baltimore Sun reporter Annie Jennemann contributed to this article.