As the opioid epidemic ravages the country, lawmakers pushing for reforms to how the drugs are prescribed have encountered a series of roadblocks from a surprising source: the lobby for physicians.

Advocates for further restrictions and physician education on the highly addictive drugs say the American Medical Association has actively lobbied against the inclusion of several recommendations by the Centers for Disease Control and Prevention and that many members of Congress are unwilling to go up against the powerful lobby.

Several of the CDC guidelines were included in a bill called Comprehensive Addiction & Recovery Act 2.0, introduced by Sen. Rob Portman (R-OH) and Sen. Sheldon Whitehouse (D-RI) in February, an update to the Comprehensive Addiction & Recovery Act that was signed into law in 2016.

Portman’s office confirmed that lobbyists from the group have told the Ohio senator’s staff they would not support provisions in the CARA 2.0 about the three-day rule or any mandatory physician education included in the bill.

The AMA opposition to proposals like limiting prescriptions of the highly addictive drugs to three-day supplies, mandating that physicians have courses about drugs and addiction, or even requiring physicians to check databases before prescribing certain drugs has confused and infuriated advocates.

During a meeting of advocates to curb opioid abuse last week, Sen. Joe Manchin (D-WV) summed up the lack of progress on certain proposals, telling the group that some of his colleagues were “too scared to take on the AMA.”

The AMA was the seventh highest lobbying spender in 2017, with $21.5 million spent. Nearly $6.8 million has been spent in 2018 so far, according to OpenSecrets.com. It gave nearly $2 million to members of Congress in 2016 and has given $519,500 so far this election cycle.

It’s a message that’s been passed on to advocates for change from other offices as well.

Gary Mendell, CEO of Shatterproof—a nonprofit aimed at “ending the devastation addiction causes families”—said he has been told by congressional staff that “the AMA will resist anything that regulates health care” on a number of issues.

Mendell added that the AMA had also pushed against other opioid-safety related measures like federal grant money that required states to require their prescribers to check the Prescription Drug Monitoring Programs before they prescribed certain controlled substance medications and shared that information with other states. PDMPs help doctors analyze a patient’s prescription drug history prior to distributing additional medication and are mandatory in more than half of states, according to the Pew Charitable Trusts, but not regulated on the federal level.

“ The AMA doesn’t dispute that doctors should check the Prescription Drug Monitor Program, but they resist a law that requires them to do that. ” — Gary Mendell, Shatterproof

“The AMA doesn’t dispute that doctors should check the Prescription Drug Monitor Program, but they resist a law that requires them to do that,” Mendell said. “I’m not about regulating health care. I don’t care if it’s regulated or not. I just care that they are safely taken care of… if doctors were doing it on their own, then we wouldn’t be having this conversation.

“It’s tragic,” Mendell, who founded Shatterproof after his son Brian died in 2011 after nearly a decade-long battle with addiction, said of the resistance to implementing potentially life-saving recommendations. “I’ll never see my son again. Other families shouldn’t have to go through this.”

In March 2016, the CDC issued a series of recommendations for how opioids are prescribed, including that physicians give the lowest possible dose once they are prescribed and limit the prescription to three days or less for acute pain (PDF). “More than seven days will rarely be needed,” the CDC noted.

The AMA contends that the group is not at odds with the CDC, pointing to the fact that it issued only recommendations and that “ efforts to codify a strict limit on prescribing opioids are inconsistent with both the language and spirit of the guidelines.”

“A strict three-day limit ignores the admonition from the CDC guideline that ‘Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient’s clinical situation, functioning, and life context,’ misstates the actual recommendation of the CDC, and applies limits to clinical situations to which they were not intended to be applied,” the AMA said in a statement.

“Limits and one-size-fits-all approaches will not end this epidemic,” the AMA said. “The AMA has urged Congress, statehouses, and payers to cover evidence-based treatment that works. Most patients with opioid use disorder have trouble accessing care as payers and others put up obstacles.”

Not all recent opioid-related legislation has been stalled, of course.

Another bill, Opioid Crisis Response Act of 2018, was recently voted out of committee. While it reauthorizes grant money to the states for three years and directs money to states where the need is most dire, it does includes funding for a “study” on prescription limitations.

Still, a spokesman for Portman said the Ohio senator was unfazed by the powerful opposition.

“People are dying around the country every single day because patients are being prescribed too many opioid pills at one time,” said Kevin Smith, a spokesman for Portman. “A three-day limit is common sense, based on CDC guidelines, and Senator Portman is going to stand up and fight for what is right.”