Painkillers are among the most widely prescribed medications in the U.S., but pharmaceutical companies and allied groups have a multitude of legislative interests beyond those drugs. From 2006 through 2015, participants in the Pain Care Forum spent over $740 million lobbying in the nation's capital and in all 50 statehouses on an array of issues, including keeping opioids accessible, according to an analysis of lobbying filings.
The same organizations reinforced their influence with more than $140 million doled out to political campaigns, including more than $75 million alone to federal candidates, political action committees and parties.
"You can go a long, long way in getting what you want when you have a lot of money," said Professor Keith Humphreys of Stanford University, a former adviser on drug policy under President Barack Obama. "And it's only when things get so disastrous that finally there's enough popular will aroused to push back."
Opioids were long reserved for severe pain due to surgery, injury or terminal diseases like cancer. That changed in the 1990s, with a surge in prescribing for more common ailments like back pain and arthritis. Marketing for new long-acting painkillers like OxyContin helped fuel the trend, along with other factors.
OxyContin-maker Purdue Pharma pleaded guilty and agreed to pay more than $600 million in fines in 2007 for misleading the public about the risks of its drug. But the painkiller continued to rack up blockbuster sales, generating more than $22 billion over the last decade.
Purdue's Washington lobbyist, Burt Rosen, co-founded the Pain Care Forum more than a decade ago and coordinates the group's monthly meetings in Washington. Purdue declined to make Rosen available for interviews and did not answer questions about its specific lobbying activities.
The company said it supports a range of advocacy groups, including some with differing views on opioids.
"In practice and governance, the Pain Care Forum is like any of the hundreds of policy coalitions in Washington and throughout the nation," the company said in a statement, adding: "Purdue complies with all applicable lobbying disclosure laws and requirements."
By spring 2014, even the head of the Food and Drug Administration was citing the statistic that 100 million Americans suffered from chronic pain.
Then-commissioner Margaret Hamburg used the figure to illustrate the importance of keeping painkillers accessible — despite the escalating toll of opioid addiction and abuse. Yet a researcher whose work contributed to the number said it was being misquoted, since most people included in the figure had common pain ailments and managed them without opioids.
Hamburg said in an emailed response that the report was "another piece of scientific literature that helped inform the broader field," and that her agency had no role in writing it.
When the FDA began developing plans to reduce misuse of long-acting, the Pain Care Forum intervened with a "strategy to inform the process," according to an internal memo from the American Pain Foundation, a now-defunct forum member.
The FDA's initial proposals included requiring doctors to undergo certification training to prescribe opioids and tracking opioid prescriptions via databases. But when the FDA sought public comment on how to proceed, the forum helped generate more than 2,000 comments against new barriers to opioids and a 4,000-signature petition opposing electronic registries, according to another pain foundation memo.
Ultimately, the agency announced far milder steps than its initial ideas: Drugmakers would fund optional classes for doctors and supply brochures to patients about opioid risks. FDA leaders said they decided requiring certification for prescribers would have been overly burdensome, disrupting care for patients and doctors.
But experts said regulators had missed a pivotal chance to curb deadly misuse and abuse with the drugs.
"The FDA failed to make a decision that could have averted many of the thousands of deaths we're seeing per year," said Dr. Nathaniel Katz, a former FDA adviser who urged the agency to make training mandatory for prescribers.
Today, the FDA is taking another look at requiring training for opioid prescribers, following a recommendation by a panel of expert advisers in May.
It was a federal agency hundreds of miles from Washington that finally sidestepped the influence of the Pain Care Forum.
Earlier this year, the Centers for Disease Control and Prevention, located in Atlanta, overcame threats of congressional investigation and legal action to publish the first federal guidelines intended to reduce opioid prescribing.
Essentially, the agency said the risks of painkillers outweigh the benefits for the vast majority of patients with routine chronic pain and that doctors instead should consider alternatives like physical therapy.
When draft guidelines emerged in September, forum members said they were not based on solid evidence, and criticized the CDC for not disclosing outside experts who had advised its effort. One pharma-aligned group, the Washington Legal Foundation, said the lack of disclosure constituted a "clear violation" of federal law. A longtime Pain Care Forum participant — now known as the Academy of Integrative Pain Management — asked Congress to investigate how the CDC developed the guidelines, though investigators found no violations.
After months of scrutiny, the CDC in December released a list of its advisers. One of 17 "core experts" had served as a paid consultant to a law firm suing opioid drugmakers.