WASHINGTON, D.C. --For more than a decade, members of a little-known group called the Pain Care Forum have blanketed Washington with messages touting 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 the drugs, which accounts for two-thirds of the world's usage.
In 2012, drugmakers and their affiliates in the forum sent a letter to U.S. senators promoting a hearing about an influential 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 to another health issue that had been declared an epidemic by federal authorities: drug overdoses tied to prescription painkillers.
Deaths linked to addictive drugs like OxyContin, Vicodin and Percocet had increased more than fourfold since 1999, accounting for more fatal overdoses 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 roughly 165,000 Americans since 2000, according to federal estimates.
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 opioid-related measures, according to an analysis of lobbying filings by the Center for Public Integrity and AP.
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.
That combined spending on lobbying and campaigns amounts to more than 200 times the $4 million spent during the same period by the handful of groups that work for restrictions on painkillers.
Meanwhile, opioid sales reached $9.6 billion last year, according to IMS Health, a health information company.
"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."
Obama gave his first speech on the opioid epidemic last fall. In July, Congress passed its first legislation targeting the crisis, an election-year package intended to expand access to addiction treatment. But the law includes little new funding and no restrictions on painkillers, such as mandatory training for prescribers, a step favored by federal advisory panels.
Obama administration officials say they have tried to strike a balance between controlling the harms of opioids and keeping them available for patients.
"We did not want to deny people access to appropriate pain care," said Michael Botticelli, Obama's drug czar. "We were all trying to figure out what the balance was, and that's still the case going forward."
Painkillers are modern versions of ancient medicines derived from the opium poppy, also the source of heroin.
Prescription opioids were long reserved for the most severe forms of pain associated with surgery, injury or terminal diseases like cancer.
That changed in the 1990s with a surge in prescribing for more common ailments like back pain, arthritis and headaches. A combination of factors fueled the trend, including new medical guidelines, insurance policies and pharmaceutical marketing for long-acting drugs like OxyContin.
The drug's manufacturer, Purdue Pharma, pleaded guilty and agreed to pay more than $600 million in fines in 2007 for misleading the public about the risks of OxyContin. But the drug continued to rack up blockbuster sales, generating more than $22 billion over the last decade.
Despite having no physical address or online presence, the Pain Care Forum hosts high-ranking officials from the White House, Food and Drug Administration and other agencies at its monthly gatherings.
Purdue's Washington lobbyist, Burt Rosen, co-founded the forum more than a decade ago and coordinates the group's meetings, which include dozens of lobbyists and executives.
Purdue declined to make Rosen available for interviews and did not answer specific questions about its lobbying activities or financial support for forum participants.
Purdue 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."
While Purdue, Endo Pharmaceuticals and other members have maintained the forum does not take policy positions, the AP and Center for Public Integrity's reporting shows the group's participants have worked together to push and draft federal legislation, blunt regulations and influence decisions around opioids.
Opioid drugmakers say they are striving to improve the safety of their products and how they are used.
They point to new harder-to-crush pills and initiatives that, among other things, allow states to share databases designed to spot "doctor shopping" by patients.
Elsewhere, experts are reevaluating the effectiveness of opioids for most forms of chronic pain, noting little long-term research.
"The biggest myth out there is that there's a conflict between reducing our dependence on opioids and improving care for patients in pain," said Dr. Caleb Alexander, co-director of Johns Hopkins University's Center for Drug Safety and Effectiveness. "It's an artificial conflict, but there are lots of vested interests behind it."