If someone were to ask you about the origins of the opioid epidemic, what would you say? Maybe false advertising, overprescribing, or a lack of alternative pain treatments? Would you blame it on doctors or pharmaceutical companies? How about this – 100 words written in a letter almost 40 years ago. That letter, published in the New England Journal of Medicine in 1980, was titled “Addiction Rare in Patients Treated With Narcotics,” and researchers are now saying that it was the true beginning of the opioid crisis.
The authors of the letter, who were from the Boston Collaborative Drug Surveillance Program at Boston University Medical Center, looked at nearly 12,000 hospitalized patients who had received at least one dose of a narcotic painkiller. They determined that there were “only four cases of reasonably well-documented addiction in patients who had no history of addiction.”
Here’s the problem. That letter has been cited over 600 times, largely by representatives from the pharmaceutical companies lobbying to get their drugs approved or to convince physicians to prescribe them. Unfortunately, most of the people pointing to the letter for evidence that opioids were safe neglected to pay attention to the details – namely that the people in the study were in a hospital setting for a short stay and had no previous trouble with addiction.
An article was published in the New England Journal of Medicine in June 2017, rebutting the 1980 letter and examining the many times it’s been referenced. According to the author of the rebuttal, Dr. David Juurlink, head of clinical pharmacology and toxicology at the University of Toronto’s Sunnybrook Health Sciences Centre, the letter was basically inconsequential when it was first published. It only described the effects on hospitalized patients, not on patients who had chronic pain and would need to take painkillers daily or around the clock. It also was describing the effects of narcotics that are no longer in use today, yet it was cited over and over again as proof that modern drugs were safe outside of the hospital setting. Part of the reason that it became so popular as part of opioid advertisements is the prestige of the journal it was published in. Pharmaceutical companies could point to it and say, “According to the New England Journal of Medicine,” and everyone would think that it had to be reputable.
It wasn’t until after the introduction of OxyContin in the mid-1990s that the number of studies citing the letter exploded. Dr. Hershel Jick, one of the authors of the 1980 letter, says that it was suddenly being used by new drug companies to advertise new pain drugs, even though none of the manufacturers ever spoke to him about it. He admits to having regrets now that he ever wrote it, saying that if he knew how it would end up being twisted, he never would have done so.
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