In the midst of a deadly national opioid epidemic, and a heated clash between addiction advocates and some groups focused on pain treatment, the US agency that oversees public health issued new guidelines for the first time advising doctors against prescribing opioids to treat chronic pain.

“It’s a game-changer,” says Andrew Kolodny, the director of Physicians for Responsible Opioid Prescribing and the chief medical officer of Phoenix House, a nonprofit drug rehabilitation organization. “It’s the first time that the federal government is clearly communicating to the medical community that opioids are not appropriate for long term use, that the risks outweigh the benefits.”

The Centers for Disease Control and Prevention (CDC) guidance – a rare move for the organization that typically leaves drug regulation to the Federal Drug Administration – was prompted by the rapidly increasing number of deaths from prescription opioids.

Though the CDC guidelines are not legally binding, the agency’s recommendations were issued despite dogged advocacy by pain management groups who receive funding from pharmaceutical companies. The release also coincides with state moves toward some of the most stringent restrictions yet on opioid prescriptions.

Earlier this week, Massachusetts Governor Charlie Baker signed a bill that limits first-time patients to seven-day prescriptions, and mandates patients to register into a statewide monitoring system. And earlier this month, Maine governor Paul LePage introduced what could become the nation’s toughest state opioid legislation, limiting prescriptions for both chronic and acute pain, and capping doses to 100 morphine milligram equivalents per day.

For Bob Twillman, executive director for the American Academy of Pain Management, the new law in Massachusetts is his nightmare incarnate, and the CDC’s move is an ominous sign that state and federal lawmakers will take increasing steps to turn CDC’s suggestions to prescribing doctors into a hard and fast rule. “It reflects a lack of experience in treating people with chronic pain,” says Twillman, who also receives funding from pharmaceutical companies.

Kolodny, says the blacklash from pain advocates – many of whom are funded by pharmaceutical companies – is akin to naysayers of global warming. “It’s a manufactured controversy,” Kolodny says.

According to the CDC, prescription opioid deaths have quadrupled since 1999, and have reached a rate of more than 40 people a day. Illicit opioids such as heroin and fentanyl, which many people turn to when pills become unavailable, bring those numbers up significantly higher. In 2014, the most recent year for which statistics are available, more than 28,647 people died from opioid overdoses.

In the guidelines, CDC advisers suggest opioids should not be prescribed as “first-line” therapy, that three days of treatment or less is sufficient, and the need to continue treatment past a week is rare. They exempt treatment for cancer, palliative care, and end-of-life care. They also advise that doctors should reassess decisions to prescribe more than 50MME a day and avoid or carefully consider prescribing more than 90MME. They recommend going over risks and goals for pain treatment with patients, and checking patients’ history of prescription opioid use in state databases.

After the guidelines were issued in draft form and left open for comment, they sparked outcry months before they were officially released. In November, the non-profit group Washington Legal Foundation – which receives grants from Purdue Pharma according to a spokesperson – accused the CDC of violating federal law by initially refusing to disclose the “Core Expert Group” who drafted the initial guidelines.

But the most notable resistance came from within the federal government, the Interagency Pain Research Coordinating Committee, which complained in a statement that there were not enough pain providers represented in the group, and questioned the science behind the CDC’s studies that opioids were not effective in treating long-term pain.

The IPRCC ultimately prompted the CDC to delay the release of the opioid guidelines and ask for more public input.

In return, the IPRCC panelists came under fire. The Associated Press reported that nearly a third of the panelists receive funding from pharmaceutical companies who make opioids. Oregon senator Ron Wyden of the committee on finance has begun an inquiry into the IPRCC and the involvement of pharmaceutical companies on government panels.

This is not the first time financial ties to pharmaceutical companies have caused problems for pain advocates. In 2012, the US Senate finance committee launched an investigation into the American Pain Foundation that found the leading pain advocacy group was receiving 90% of it’s funding from pharmaceutical companies. It disbanded before the Senate finance committee could release a report on their findings.

The scandal at the foundation came after executives at Purdue Pharma, the company that makes OxyContin, got in trouble for their direct influence in the medical community. The company pleaded guilty and agreed to pay a $600m penalty to the US Justice Department in 2007 over charges of “misbranding” the product to doctors and patients as non-addictive due to it’s time-release sealant, which could be easily removed. The pharmaceutical company settled a similar lawsuit with the state of Kentucky for $24m last December.

Years of misinformation, and a lack of official guidelines have made prescribing large amounts of opioids for chronic pain common, building up a “glut of opioids” in people’s medicine cabinets, Kolodny says. He said the practice has become so common that drug companies ran a commercial during the Super Bowl for a drug treating the side effects of opioid-induced constipation. The ad was funded by pharmaceutical companies AstraZeneca and Daiichi Sankyo, on behalf of pain advocacy non-profits.

Dr Deborah Dowell, the lead author of the CDC guidelines, says the considerations of pain advocates were addressed in the most recent draft and that the agency softened the final version to allow for recommendations of up to seven days of treatment and doses of more than 90MME.

Twillman says theses tweaks from the previous version were not significant. “I’m disappointed they didn’t really take any of our advice to heed.”

He also said many of the alternative methods of care for acute pain recommended in the guideline such as massages and yoga, are not covered by Medicare. “We’ve been calling CDC for some time to try to make some of these other treatments widely available so we could reduce the need for opioids.”

In a statement, Deb Houry, the CDC’s director of the National Center for Injury Prevention and Control, responded that the guidance “does acknowledge cost and access as real barriers to a broader array of therapies” and that the agency is committed to working with federal partners to strengthen coverage of non-pharmacologic treatments.

The Cancer Action Society Cancer Action Network also noted its displeasure the guidelines. Though the CDC specifies that these parameters are not applicable to cancer patients, the advocacy organization’s president Chris Hansen said in a statement: “The guidelines disregard the impact on cancer survivors.”

“Pain does not end when an individual completes treatment. Most often, cancer patients deal with lasting effects from their disease or treatment including pain for a significant period of time or indefinitely,” he said.

The organization also receives significant funding from pharmaceutical companies - $2.184 million in 2015 according to the organization. But spokeswoman Alissa Crispino said it’s a very small part of their revenue. “The American Cancer Society Cancer Action Network (ACS CAN) had $36.4 million in revenues in 2015 – approximately $32 million through a grant from the American Cancer Society and nearly $4.4 million through direct contributions,” Crispino said.

She added that the group’s “only constituents are cancer patients, survivors, and their loved ones nationwide.”