A letter to the editor of the New England Journal of Medicine has been called the genesis of the opioid crisis. This might seem crazy but it is very true and while looking back doesn’t fix the present it does shine light on the cause of today’s opioid crisis.
This letter to the editor was published in the January 10th, 1980 edition of the New England Journal of Medicine. It was authored by Herschel Jick, MD and Jane Porter. It is one paragraph of five sentences. It contains two references to journal articles published with Dr. Jick as a contributing researcher; one published in 1970 the other in 1978. The authors reviewed the records of 39,946 hospitalized medical patients. They noted 11,882 patients who received at least one narcotic prescription and only four cases of reasonably well documented addiction in patients who had no history of addiction. The drugs implicated in the cases of addition were meperidine, Percodan, and hydromorphone. Based on these observations the authors concluded that addiction is rare in hospitalized patients who are given narcotics and have no history of addiction.
First off it is important to note that this is a letter to the editor, not a peer reviewed published research paper. It should carry little weight, meaning it should not be used to drive decision making. Really it should be used as a stepping off point for a real study to be published in a peer reviewed journal. Secondly these authors reviewed records of hospitalized patients, not patients with chronic pain who were prescribed a narcotic in an outpatient setting. These patients where under constant hospital care, not out living their life. Lastly there is no mention of dose, how long a patient took a medication, or what the condition the patient was being treated for that precipitated the use of a narcotic. All of the things that would be important to note to help physicians determine when, for what conditions, and for how long a patient should be given a narcotic. It is possible each patient was given a narcotic for one day or 30 days, we don’t know. These are just a few of the major holes that a letter to the editor creates when it isn’t a real published study.
This is all important because this one paragraph letter to the editor has been cited in 608 studies since 1980. Of these citations, 72.2% used the letter as evidence that addiction in opioid-treated patients is rare; 80.8% did not mention that the original letter described inpatient findings. After the release of Oxycontin in 1995 this letter was often cited to support the idea that opioid drugs were not addictive in the outpatient setting. Physicians were told the risk of addiction in using opioids was low and this letter to the editor played a significant role.
More than 183,000 deaths from prescription opioids occurred in the United States between 1999 and 2015, opioid use is creating around half of all heroin users today as people with a legal pain killer find the illegal drug is easier to get and cheaper. This didn’t start overnight it has been slowly occurring and some people call this letter the genesis of the opioid crisis today. To their credit the authors claim their letter was to only show that short term, hospital monitored use was safe. They never intended this study to be used to support long term, outpatient use of opioid drugs. The blame solely rests on the pharmaceutical companies looking to make the most out of their research and development investment in drugs like Oxycontin. It is pharmaceutical companies that distorted the data in an attempt to convince physicians and the population that opioid drugs are safe but they are not safe and we are paying the price today.
I am not 100% against medications, I believe there is a time and a place for some medications. For opioids they tend to make the most sense when a patient is suffering from pain caused by cancer. Opioids never make sense for patients with chronic pain, in fact I have read that, based on the statistics, it takes only about 10 days of use to become addicted to an opioid. If you are given the option of taking an opioid to manage your chronic pain you should pass because the odds are not in your favor that this will not destroy your life.