Thursday, May 26, 2016

This one-paragraph letter may have launched the opioid epidemic – Business Insider

Over the past decade, the US has actually undergone an opioid epidemic. Prescriptions for opioid painkillers like oxycodone, hydrocodone, fentanyl, and morphine have actually skyrocketed and, along with them, the number of overdoses related to opioids.

In 2014, deaths from opioid-related drug overdoses reached a brand-new higher of 28,647, according to a January report from the Centers for Disease Control and Prevention (CDC).

But the trend has actually been decades in the making.

This explosion in opioid prescriptions began in the early 1990s along with “a big push” from medical groups that doctors were under-treating pain, according to Dr. Ted Cicero, a professor of psychiatry at Washington University in St. Louis and an opiate-use researcher. 

One of the primary justifications for this increase, used by doctors, pharmaceutical companies, and researchers alike was a single paragraph printed in the  January 10, 1980 issue of the New England Journal Of Medicine:


To the Editor: Recently, we examined our current files to determine the incidence of narcotic addiction in 39,946 hospitalized medical patients’ that were monitored consecutively. Despite the fact that there were 11,882 patients that received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients that 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 along with no history of addiction.



Boston Collaborative Drug

Surveillance Program

Boston University Medical Center

Waltham, MA 02154

The analysis mentioned in the letter, which was authored by Dr. Hershel Jick, was not included. 

Specifically, the letter was used to support the assertion that “much less compared to 1%” of opioid users become addicted to the drugs.

Jick’s analysis proved no such thing. The study analyzed a database of hospitalized patients at Boston University Medical Focus that were given small doses of opioids in a controlled setting to ease suffering from acute pain. These patients were not given longterm opioid prescriptions which they’d be free to administer at home.

Nevertheless, medical groups like the American Pain Society and the American Pain Foundation used the letter as a jumping off point and began calling pain the “fifth vital sign” that doctors must attend to. Pharmaceutical companies like Purdue Pharma introduced powerful brand-new painkillers such as MS Contin and Oxycontin, extended-release pills along with a pretty large dose of morphine or oxycodone respectively that is designed to be released slowly in to a person’s physique over a 12 or 24-hour period. Major pain specialists began encouraging doctors to prescribe opioids liberally to their pain patients, despite long-held fears of addiction.

As detailed by investigative journalist Sam Quinones in Dreamland: The True Tale of America’s Opiate Epidemic,” his investigation in to the causes of the heroin crisis, the Porter and Jick letter was referenced repeatedly to justify the increase in liberal prescriptions of opioid painkillers, including in the following:

  • A 1990 post in Scientific American, where it was called “an extensive study;”
  • A 1995 post in Canadian Family Physician, where it was called  “persuasive;”
  • A 2001 Time Magazine feature, which said it was a “landmark study” demonstrating that the “exaggerated fear that patients would certainly become addicted” to opiates was “basically unwarranted;”
  • A 2007 textbook Complications in Regional Anesthesia and Pain Medicine, which said it was “a landmark report” that “did much to counteract” fears that pain patients treated along with opioids would certainly become addicted. 
  • 1989 monograph for the National Institutes of Health which asked readers to “think about the job [of Porter and Jick].”

As of May 24, 2016, the Porter and Jick letter has actually been cited 901 times in scholarly papers, according to a Google Scholar search.

The most influential citation of the Porter and Jick letter joined a 1986 paper on the “chronic use of opioid analgesics in non-malignant pain” by Dr. Russell Portenoy and Kathy Foley in Pain, the official journal of the American Pain Society. In the paper, Portenoy and Foley reviewed the cases of 38 cancer patients along with chronic pain that used opioids. Only two became addicted.

We conclude that opioid maintenance therapy can easily be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients along with intractable non-malignant pain and no history of drug abuse.” Portenoy and Foley wrote.

Portenoy and Foley’s paper, bolstered by the Porter and Jick letter, became an even broader justification for doctors to prescribe opioids liberally for common injuries such as spine pain.

Over time, the Porter and Jick letter, and its claim that “much less compared to 1%” of opioid users became addicted, became “gospel” for medical professionals, Dr. Marsha Stanton told Quinones.

“I used [Porter and Jick] in lectures all the time. Everybody did. It didn’t matter whether you were a physician, a pharmacist, or a nurse; you used it. No one disputed it. must we have? Of course we must have,” Stanton said.

In 1996, the American Pain Society and the American Academy of Pain Management issued a “landmark consensus,” written in section by Portenoy, saying that there is little risk of addiction or overdose in pain patients. The consensus cited both the “much less compared to 1 percent” addiction figure and the Porter and Jick letter.

In an interview released by Physicians for Responsible Opioid Prescribing in 2011, Portenoy confessed that he used the Porter and Jick letter, along along with various other similar studies on opioid use, to encourage more liberal prescribing of opioids: 

None of [the papers] represented real evidence, and yet just what I was attempting to do was to develop a narrative so that the primary care audience would certainly consider this short article in toto and feel more comfort about opioids in a method they hadn’t before. In essence this was education to destigmatize [opioids] and because the primary goal was to destigmatize, we often left evidence behind.

Here’s the full video:

When asked by Quinones years later about the letter, Jick called it “an amazing thing.”

“That particular letter, for me, is pretty near the bottom of a long list of studies that I’ve done. It’s useful as it stands because there’s nothing else like it on hospitalized patients. However if you read it carefully, it does not speak to the level of addiction in outpatients that take these drugs for chronic pain.”

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