In 1980, Dr. Hershel Jick, a drug specialist at Boston University Medical Center, and graduate student Jane Porter published a letter in The New England Journal of Medicine stating opioid medications are safe to use in the treatment of pain and pose no risk of narcotic addiction to patients in certain conditions.
Their brief report documents that out of almost 12,000 hospitalized patients treated with narcotic preparations, only four patients with no previous record of addiction became hooked on their medication — which the authors cite as being meperidine (in the case of two patients), Percodan (in the third patient), and hydromorphone (in the fourth patient).
Since then, their note — a one-paragraph letter to the editor tallying just 100 words — has circulated in the scientific literature, being widely used as a reference to support the routine prescription of opioid drugs in pain management.
Cited 608 Times In Opioid Studies
A Canadian team of researchers investigated the impact of this short letter in scientific literature and tracked down all the instances it was quoted since its publication.
The scientists, led by David Juurlink from the Sunnybrook Research Institute of Toronto, argue the source of the current U.S. opioid epidemic can be traced back to this 1980 letter.
The team conducted an analysis, featured Wednesday, June 1, in the same medical journal, which shows the five-sentence letter was cited 608 times, compared with the average 11 citations for other letters published in the same period.
The authors point out that on 439 occasions, or 72 percent of the time, the 1980 note was used as a reference to prove patients treated with opioids rarely became addicted to the drugs.
Juurlink's team also documents a dramatic surge in the prescribing of strong opioid medication, such as oxycodone, over the last 20 years.
As a result of this practice, millions of Americans became addicted to opioid painkillers between 1999 and 2015, and more than 183,000 people died after taking prescription opioids.
"The crisis arose in part because physicians were told that the risk of addiction was low when opioids were prescribed for chronic pain. A one-paragraph letter that was published in the Journal in 1980 was widely invoked in support of this claim, even though no evidence was provided by the correspondents," writes Juurlink's team in the paper.
Misleading Citations Sparked The Rise In Opioid Painkiller Prescriptions
The high number of citations, however, is not the only concern. More worrying is the uncritical, misleading way in which the 1980 letter was cited as proof that prescription opioid painkillers aren't addictive.
Juurlink's research revealed that in 491 cases, or 81 percent of citations, the citing authors failed to mention the patients referred to in the letter were being treated in a hospital, and therefore the note's conclusions wouldn't necessarily apply to outpatients or people treated for chronic pain.
Among the inaccurate citations documented by Juurlink's team is a 1994 reference from the journal Seminars in Oncology, in which the citing authors mistakenly say Jick and Porter's patients were being treated for cancer pain.
The 1980 letter was again uncritically cited in 2002 in the International Journal of Clinical Practice, where Dr. Sian Iles, an associate professor of radiology at Dalhousie University in Halifax, Nova Scotia, said doctors are reluctant to prescribe opioid painkillers due to addiction concerns even though "there is no evidence that this occurs when prescribing opioids for pain."
Another example is that of Nancy Kowal, a nurse at the University of Massachusetts Memorial Medical Center in Worcester, who blatantly misquoted the letter in a 1999 report in Nursing Economics.
"This pain population with no abuse history is literally at no risk for addiction," Kowal wrote at the time.
Juurlink's team concludes the 1980 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," state the Canadian researchers.
The Connection With OxyContin
Juurlink's team observed a spike in the number of citations after 1996, when Purdue Pharma introduced OxyContin as a new pain relief treatment.
After OxyContin's introduction, the number of citations rose to 30 a year, and the references were typically meant to dissipate worries over opioid addiction risks.
"It's difficult to overstate the role of this letter," said Juurlink, adding the 1980 note "was the key bit of literature that helped the opiate manufacturers convince front-line doctors that addiction is not a concern."
"In 2007, the manufacturer of OxyContin and three senior executives pleaded guilty to federal criminal charges that they misled regulators, doctors, and patients about the risk of addiction associated with the drug," shows his team in their analysis.
At the same time, the author of the 1980 letter explains his report only referred to patients treated with opioids in the hospital for a short period of time. He shows his conclusions have no bearing on long-term outpatient use.
"I'm essentially mortified that that letter to the editor was used as an excuse to do what these drug companies did," said Jick in a statement.
"They used this letter to spread the word that these drugs were not very addictive," Kick added.
