Even by Super Bowl standards, the constipation ad shown Sunday was an eye-grabber.
The main character glances sadly at another middle-aged man who has just come out of a bathroom looking triumphant.
"If you need an opioid to manage your chronic pain, you may be so constipated it feels like everyone can go — except you," a narrator says.
The black-and-white ad was promoting awareness of a condition known as opioid-induced constipation, a formidable and extremely common side effect of pain medications such as Oxycontin.
What many viewers didn't know is that the pharmaceutical companies that funded the ad, AstraZeneca and Daiichi Sankyo, are hoping to profit from a controversial market that has arisen alongside the nation's opioid addiction crisis.
The companies have spent hundreds of millions of dollars to purchase the rights to make and sell Movantik, a first-of-its-kind constipation drug for painkiller users that reached the market last year. The ad did not mention the drug.
AstraZeneca also gave hundreds of thousands of dollars last year to pain advocacy nonprofits that promote awareness of the condition, according to its most recent financial disclosures from the first half of 2015. Four of those groups put their names on the ad.
With pain pill use booming across the country, the U.S. market for treating opioid constipation is projected to reach at least $500 million a year by 2019, according to recent estimates by the market research firm GlobalData.
The ad, which has gotten 1.7 million views on YouTube as of Wednesday, has drawn criticism from federal and local officials for not mentioning the issue of opioid addiction.
"Next year, how about fewer ads that fuel opioid addiction and more on access to treatment," White House Chief of Staff Denis McDonough complained on Twitter.
The police chief of Burlington, Vt., Brandon del Pozo, called the ad "extraordinarily tone-deaf."
"The side effect that big pharmaceutical companies need to be warning Americans about is addiction, not constipation," said Del Pozo, who said the number of overdoses in his city had more than doubled last year compared with the previous three years.
If "Big Pharma" was going to spend millions of dollars to talk about opioids during the Super Bowl, Del Pozo said, "The only thing it should be saying is, 'Watch out, we've created something addictive, we're here to help, we're all in this together, we need to get you guys off of this drug.'"
Some public figures jumped on the ad as well. "Was that really an ad for junkies who can't [poop]? America, I luv ya but I just can't keep up," TV host Bill Maher tweeted.
But advocacy groups for pain patients dismissed the criticism and the suggestion that all painkiller users are addicts.
"I don't know that many people who become addicted who say, 'I'm going to pick and choose what I'm going to be addicted to based on the side effect of that drug,'" said Paul Gileno, the president and founder of the advocacy nonprofit U.S. Pain Foundation, whose group has received grant money from AstraZeneca.
Opioid-induced constipation is so unmanageable that many legitimate opioid users quit the drugs and choose to live in pain instead, research suggests.
"It's scary and really uncomfortable," said Cynthia Toussaint, founder of the Los Angeles-based pain advocacy nonprofit For Grace, who suffers from chronic pain and whose group also received financial sponsorship last year from AstraZeneca.
In past treatment, Toussaint said, sometimes she had to choose between being in pain or taking a painkiller and being constipated.
"It's not fun," Toussaint said. "It's a balance whether you take the opioid or you don't.... I take as few as I can mostly because the constipation is so awful."
She and other advocates said they backed the ad because doctors and patients don't often discuss opioid-induced constipation, because the condition is embarrassing or not widely known.
Pharmaceutical companies have long promoted not only the drugs they sell but also the conditions they are intended to treat.
AstraZeneca said the campaign is designed to lift opioid-induced constipation out of the realm of taboo and make it a widely recognized problem among doctors and patients.
"The reality is there are millions of Americans that suffer with this condition, and there has been little dialogue around this," said Dave Fredrickson, vice president of specialty care at AstraZeneca.
Fredrickson acknowledged that raising awareness of the condition would inevitably raise awareness of the new drug that treats it. The Super Bowl ad directed viewers to a website, OICisDifferent.com, that in turn offers visitors a link to "discover a prescription treatment option" — Movantik.
Fredrickson said traffic to the website had jumped 400% after the Super Bowl.
Last year, the drug companies signed up Olympian Jackie Joyner-Kersee to give personal testimonials about her experience with opioid-induced constipation.
Advocacy groups that put their names on the Super Bowl ad said the grants they received from AstraZeneca did not require them to do so and were for other educational projects.
"They wanted our perspective ... 'Is it good for people with pain, is it sensitive enough, does it raise the awareness that we're all trying to raise together?'" Gileno said.
Penney Cowan, head of the American Chronic Pain Assn., of Rocklin, Calif., said her group — which received at least $175,000 in grant money from AstraZeneca in 2015 for promoting awareness of opioid-induced constipation — would not have endorsed the ad if it directly promoted the drug.
"It really was an educational piece to help people understand it's OK to talk about it, talk to your health provider," Cowan said.
Opioids work by dampening pain receptors in the brain. But the same chemical also dampens similar receptors in the stomach, making bowel movements more difficult.
Some studies suggest that 40% to 90% of painkiller users suffer constipation as a side effect.
Prescriptions for pain drugs have jumped at least 300% since 1999, with U.S. doctors now writing more than 240 million opioid prescriptions a year.
In 2014, officials linked 28,648 deaths to opioid overdoses, and last week the White House proposed $1.1 billion in new funding to expand treatment for what it calls an epidemic.