The makers of prescription painkillers have adopted a 50-state strategy that uses hundreds of lobbyists and millions in campaign contributions to help kill or weaken measures aimed at stemming the tide of prescription opioids.
Prescription opioids are the cousins of heroin and are prescribed to relieve pain. The drugs are at the heart of a crisis that has cost 165,000 Americans their lives and pushed countless more to addiction.
Sales of the drugs quadrupled from 1999 to 2010, rising in tandem with overdose deaths. Last year, 227 million opioid prescriptions were doled out in the U.S., enough to hand a bottle of pills to nine out of every 10 American adults.
Arkansas health and law enforcement officials have described the misuse of opioids as an "epidemic."
Across the state, the ratio of prescriptions to patients exceeds national averages. There are more prescriptions written than there are residents in the state, according to 2015 figures from IMS Health, a company that reports being the largest vendor of U.S. physician prescribing information.
And drug-related deaths in Arkansas, attributed largely to opioid overdoses, also jumped at least 25 percent since 2006, the Centers for Disease Control and Prevention found.
In light of the numbers, drugmakers vow they're combating the addiction epidemic.
But The Associated Press and the Center for Public Integrity found that drugmakers often employ a statehouse playbook of delay and defend that includes funding advocacy groups that use the veneer of independence to fight limits on their drugs, such as OxyContin, Vicodin and fentanyl, the narcotic linked to pop singer Prince's death.
Lawmakers across the country have started trying to limit the flood of prescriptions and prevent overdoses.
In 2011, Arkansas legislators approved the creation of the Prescription Drug Monitoring Program, a database that tracks how controlled substances are prescribed and dispensed to prevent and reduce the illicit use of opioids and "doctor shopping" -- those patients who go from doctor to doctor seeking opioid prescriptions.
Authorized pharmacists, physicians and law enforcement investigators check the database, which is linked to 16 other state-based monitoring programs, about 2,700 times a day, according to the Arkansas Center for Health Improvement. Texas is expected to join the network soon.
Some contend that similar legislative efforts in other states have been thwarted by the opioid industry.
In 2012, for example, New Mexico considered a bill to limit initial prescriptions of opioids for acute pain to seven days to make addictions less likely and produce fewer leftover pills that could be peddled illegally. The bill died in the House Judiciary Committee.
"The lobbyists behind the scenes were killing it," said Bernadette Sanchez, the Democratic state senator who sponsored the measure.
Lobbyists for opioid-makers and their allies declined to comment. But those groups had 15 lobbyists registered in New Mexico that year, up from nine the previous year. Among them were longtime players considered among the most influential advocates in Santa Fe.
Most judiciary committee members received drug industry contributions in 2012. Overall that year, drug companies and their employees contributed nearly $40,000 to New Mexico campaigns -- roughly 70 percent more than in previous years with no governor's race on the ballot.
Nationwide, the opioid industry and its allies spent more than $880 million on lobbying and campaign contributions from 2006 through 2015 -- more than 200 times what those advocating for stricter policies spent and eight times more than the influential gun lobby recorded for similar activities during that same period, the AP and Center for Public Integrity found.
The drugmakers and allied advocacy groups -- such as the American Cancer Society Cancer Action Network -- also employed an annual average of 1,350 lobbyists in state capitals from Olympia to Tallahassee during that span, when opioids' addictive nature came under increasing scrutiny.
"The opioid lobby has been doing everything it can to preserve the status quo of aggressive prescribing," said Dr. Andrew Kolodny, an outspoken advocate for tighter opioid regulation. "They are reaping enormous profits from aggressive prescribing."
Lobbying efforts are not as prevalent in Arkansas when compared with other states, however.
In their investigation, the AP and Center for Public Integrity ranked Arkansas 30th of all states to receive dollars from the opioid lobby and 21st in the number of opioid lobbyists working with Arkansas politicians.
Only $63,550 in campaign contributions went to lawmakers in 2014 at the state and federal level combined, according to data compiled by the AP and Center for Public Integrity.
While this is more than Arkansas politicians have received from opioid industry groups -- about $24,500 was received the previous year, for instance -- the state is ranked in the bottom half of the country for money received from the opioid lobby.
Campaign records also show that U.S. Sen. Tom Cotton received $49,300 since 2012 and Sen. John Boozman received $43,150 since 2008 from the pharmaceutical lobby.
The campaigns of former senators Blanche Lincoln and Mark Pryor each received more than $110,000. Of all current state-level politicians, Lt. Governor Tim Griffin received the most -- a total of $36,211, from 2009 until 2014.
The opioid industry says it is committed to solving the problems linked to its painkillers. Major opioid-makers have launched initiatives to, among other things, encourage more cautious prescribing.
"We and our members stand with patients, providers, law enforcement, policymakers and others in calling for and supporting national policies and action to address opioid abuse," the industry group Pharmaceutical Research and Manufacturers of America said.
Doctors continue to prescribe opioids for ailments such as back pain and headaches, even though studies have shown weak or no evidence that the drugs are effective ways to treat routine chronic pain -- even though they come with the risk of addiction.
In 2007, executives at Purdue, the maker of OxyContin, pleaded guilty to misleading the public about the drug's addictive nature and agreed to pay $600 million in fines.
Pharmaceutical lobbyists are now pushing bills to fight opioid abuse that also promote a new product that pads their bottom lines: patent-protected abuse-deterrent opioids. They lobby for laws requiring insurers and pharmacists to give preferential treatment to the drugs, even though some experts say their abuse-deterrent qualities are easily circumvented.
So far, lawmakers have introduced scores of bills on the topic, with at least 21 using nearly identical language -- some of it supplied by lobbyists.
One of the drugmakers' most powerful political engines is their financial support for opioid-friendly advocacy groups.
Such groups led the countercharge in Tennessee in 2014 when Republican state Rep. Ryan Williams began work to stanch the flow of prescription painkillers, alarmed by a rising number of drug-addicted babies. More than 900 were born the year before, nine times the amount in 2001, many of them hooked on the prescription opioids their mothers had taken.
Tennessee, West Virginia and Alabama are the only states with more opioid prescriptions per-capita than Arkansas. Mississippi just trails the state.
Doctors told Williams that part of Tennessee's problem was a 2001 law that allowed clinicians to refuse to prescribe powerful narcotics only if they steered patients to an opioid-friendly doctor.
Williams' mission to repeal the law failed that year, after lobbying from the American Cancer Society Cancer Action Network and the Academy of Integrative Pain Management -- opposition that surprised Williams since prescribing painkillers for cancer patients would have remained legal.
Both the academy and the cancer group have been active across the country, making the case that lawmakers should balance efforts to address the opioid crisis with the needs of chronic pain patients. Between them, they have contacted legislators and other officials about opioid-related measures in at least 18 states.
The society's annual ranks of about 200 lobbyists around the country opposed opioid restrictions even in some cases where they specifically exempted cancer patients.
The Cancer Action Network listed four major opioid makers who donated at least $100,000 in 2015 and five more who gave at least $25,000. Companies that offer such sums get one-on-one meetings with the group's leaders. The network said 6 percent of its funding last year came from drugmakers.
The academy, until recently known as the American Academy of Pain Management, receives 15 percent of its funding from pharmaceutical companies, according to Executive Director Bob Twillman.
Its state advocacy project is 100 percent funded by drugmakers, but he said that does not mean it is beholden to pharmaceutical interests.
"Most of the time we're saying, 'Gosh, yes, there should be some limits on opioid prescribing, reasonable limits,'" Twillman said, "but I don't think they would be in favor of that."
Purdue Pharma -- the maker of OxyContin and one of the largest opioid producers by sales -- gives to both groups. The company said in a statement that it contributes to a range of advocates, including some with differing views on opioid policy.
"It is imperative that we have legitimate policy debates without trying to silence those with whom we disagree," the statement said.
As for Williams, he tried again last year to repeal Tennessee's opioid prescribing law -- and succeeded, even though the cancer network still opposed the repeal. The extra year had given Williams and his co-sponsor time to help educate their fellow lawmakers, he said.
Information for this article was contributed by Matthew Perrone of The Associated Press and by Amanda Claire Curcio of the Arkansas Democrat-Gazette.
A Section on 09/19/2016