For more than a decade, members of a little-known group called the Pain Care Forum have blanketed Washington with messages about prescription painkillers' vital role in the lives of millions of Americans, creating an echo chamber that has quietly derailed efforts to curb U.S. consumption of drugs like OxyContin, Vicodin and Percocet.
In 2012, drugmakers and their affiliates in the forum sent a letter to U.S. senators promoting a recent report on a "crisis of epidemic proportions": pain in America. Few knew the report stemmed from legislation drafted and pushed by forum members and that their experts had helped author it. The report estimated more than 100 million Americans — roughly 40 percent of adults — suffered from chronic pain, an eye-popping statistic that some researchers call deeply problematic.
The letter made no reference, however, to another health issue that had been declared an epidemic by federal authorities: drug overdoses tied to prescription painkillers. Deaths linked to addictive opioid drugs had increased more than fourfold since 1999, accounting for more deaths in 2012 than heroin and cocaine combined.
An investigation by The Associated Press and the Center for Public Integrity reveals that similar feedback loops of information and influence play out regularly in the nation's capital, fueled by money and talking points from the Pain Care Forum, a loose coalition of drugmakers, trade groups and dozens of nonprofits supported by industry funding that has flown under the radar until now.
Hundreds of internal documents shed new light on how drugmakers and their allies shaped the national response to the ongoing wave of prescription opioid abuse, which has claimed the lives of 165,000 Americans since 2000, according to federal figures.
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 opioids, 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.
The final guidelines appeared in March. The first recommendation for U.S. doctors was unequivocal: "Opioids are not first-line therapy" for routine chronic pain. It was a statement considered common practice by many doctors as recently as the early 1990s, a decade before the Pain Care Forum formed in Washington.
Reporters Geoff Mulvihill of The Associated Press and Liz Essley Whyte of The Center for Public Integrity contributed to this report.
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