How 5 sentences in a leading medical journal shaped the opioid crisis
More than 183,000 people died from overdoses related to prescription opioid painkillers like oxycodone, hydrocodone, fentanyl, and morphine over the last 15+ years.
At the same time, prescriptions for the drugs have "increased dramatically," according to a new analysis published Wednesday in the New England Journal of Medicine.
The analysis looked at how a letter to the editor published in the journal in 1980 may have helped shape that prescribing trend.
The letter outlined cases of narcotic addiction in a hospital's medical records, and concluded that addiction was rare in the instances when opioids were administered in the hospital.
Here's the text of the original letter:
ADDICTION RARE IN PATIENTS TREATED WITH NARCOTICS
To the Editor: Recently, we examined our current files to determine the incidence of narcotic addiction in 39,946 hospitalized medical patients' who were monitored consecutively. Although there were 11,882 patients who received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients who had a history of addiction. The addiction was considered major in only one instance. The drugs implicated were meperidine in two patients, Percodan in one, and hydromorphone in one. We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.
Jane Porter
Herschel Jick, M.D.
Boston Collaborative Drug
Surveillance Program
Boston University Medical Center
Waltham, MA 02154
The letter was later used by doctors, pharmaceutical companies, and researchers to downplay concerns of how addictive long-term use of the drugs could be. Many pointed to it as evidence that addiction was rare even when opioids were used to manage chronic pain outside hospitals, despite the fact that the letter didn't even address that scenario.
Dr. David Juurlink, a professor at the University of Toronto and one of the authors of the analysis, explained how that brief letter to the editor changed the conversation around opioids:
Between 1981 and 2017, the letter was cited 608 times, according to the analysis. In roughly 80% of those cases, the authors citing the letter didn't note that it was just about patients using painkillers while in the hospital. As such, the letter's findings frequently overstated.
"In reality, medical opioid addiction is very rare," one of the papers that cited the letter said. "In Porter and Jick's study on patients treated with narcotics, only four of the 11,882 cases showed psychological dependency."
Juurlink and his co-authors found that this, and other papers, overstated the conclusions of the 1980 letter, suggesting that the letter referred to general use of opioids and not just in a hospital setting. In addition, the analysis referenced in the letter was never submitted to a journal or peer-reviewed.
The researchers concluded that the short, five-sentence letter was "heavily and uncritically cited as evidence that addiction was rare with long-term opioid therapy."
"We believe that this citation pattern contributed to the North American opioid crisis by helping to shape a narrative that allayed prescribers' concerns about the risk of addiction associated with long-term opioid therapy," the authors wrote.
Juurlink also noted in a tweet that there seemed to be a spike in citations around the mid-1990s, around the same time the FDA approved OxyContin, the branded version of oxycodone that's made by Purdue Pharma.
Purdue Pharma said in a statement regarding the NEJM analysis:
"The opioid crisis is a complex societal problem that demands a diverse group of stakeholders to address it. Purdue accepted responsibility for the actions some of its employees took prior to 2002, and since that time we have led the industry in developing abuse-deterrent technology, advocating for the use of prescription drug monitoring programs and supporting access to Naloxone -- all important components for combating the opioid crisis. OxyContin accounts for less than 2% of all opioid pain prescriptions nationally and focusing on only one aspect of the issue ensures we will not adequately solve it. Addressing the opioid crisis is one of our top priorities and we will continue to work to find comprehensive solutions."
Jick, one of the authors on the letter, told the AP that his letter only referred to people using opioid painkillers for a short period of time in the hospital, not for chronic use.
"I'm essentially mortified that that letter to the editor was used as an excuse to do what these drug companies did," he said.