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?????????????????????????????????????????????????Sunday, June 4, 2017
How a short letter in a prestigious journal contributed to the opioid crisis
A pharmacy tech separates hydrocodone bitartrate and acetaminophen tablets in August 2010. (AP/Sue Ogrocki)
Long before opioid abuse exploded into a public health crisis, before
drugs such as OxyContin and Vicodin claimed hundreds of thousands of
American lives and ruined countless others, one respected Boston
University doctor had a question he wanted answered.
How often, Dr. Hershel Jick wondered, do hospital patients grow addicted to their narcotic pain treatments?
To find out, Hershel and his assistant, a graduate student named Jane
Porter, reviewed troves of hospital records. Their conclusions were
optimistic: Out of nearly 12,000 hospital patients treated with such
painkillers, just four had become addicted. Only one case was considered
severe. They wrote up the good news in a one-paragraph, five-sentence letter to the New England Journal of Medicine.
“We conclude,” read the letter, “that despite widespread use of narcotic
drugs in hospitals, the development of addiction is rare in medical
patients with no history of addiction.”
That was in January 1980. Over the following decades, the letter was
invoked by doctors, academics, pharmaceutical companies and others as
evidence that few users would develop addictions and that liberal
prescription was justified. Of course, the analysis proved nothing of
the sort, nor did it set out to. But the widely misread letter — now so
well known it’s been nicknamed “Porter and Jick” — has been blamed for
fueling the country’s opioid epidemic.
On Wednesday, the New England Journal of Medicine published a note from
four Canadian researchers that shows the true scope of the letter’s
influence, in what may be a first for the academic journal. The authors,
led by Pamela T.M. Leung of the University of Toronto, found that
“Porter and Jick” had been cited 608 times by other scholars — often inaccurately and uncritically.
Nearly 500 articles neglected to note that the letter concerned only
hospitalized patients whose treatments were overseen by medical staff,
rather than people prescribed take-home painkillers for, say, arthritis
or minor injuries, the researchers found. A majority of the articles
also cited the letter as evidence that addiction was rare in patients
who took opioids. Other articles “grossly misrepresented” the letter’s
findings, Leung and her team wrote.
“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,” read the note which, like “Porter and Jick,” appeared in the
journal’s letter to the editor section.
“The crisis arose in part because physicians were told that the risk of
addiction was low when opioids were prescribed for chronic pain,” it
read. “Our findings highlight the potential consequences of inaccurate
citation and underscore the need for diligence when citing previously
published studies.”
Respondents
who took part in The Washington Post-Kaiser Family Foundation survey on
long-term, opioid painkiller use share their experiences of living with
pain. (Monica Akhtar,Erin Patrick O'Connor/The Washington Post)
Some of the articles that cited “Porter and Jick” wildly inflated its
conclusions, according to Leung and her team. “This pain population with
no abuse history is literally at no risk for addiction,” read one
article from 1998. “Medical opioid addiction is very rare,” read another
from 2002.
If those claims sound ridiculous now, in 2017, it’s because they are.
More than 183,000 people have died in the United States from
prescription opioid overdoses since 1999, according to the Center for Disease Control and Prevention. Millions of other Americans struggle with painkiller addiction.
For Jick, who is still a drug specialist at Boston University School of
Medicine, the letter was never intended to have any bearing on
painkiller use outside short-term hospital visits.
“I’m essentially mortified that that letter to the editor was used as an excuse to do what these drug companies did,” he told the Associated Press on Wednesday. “They used this letter to spread the word that these drugs were not very addictive.”
An editor’s note on
the New England Journal of Medicine now reads: “For reasons of public
health, readers should be aware that this letter has been ‘heavily and
uncritically cited’ as evidence that addiction is rare with opioid
therapy.” It links to the review by the Canadian researchers.
The story behind the letter was documented extensively by journalist Sam Quinones in his 2015 book “Dreamland,” an account of the opioid crisis in the United States.
According to Quinones, the letter seemed to go largely unnoticed until
1986, when it was cited in a paper in Pain, the journal of the American
Pain Society. From there, other scholars began to repeat its findings —
often, as Quinones notes, without the important context that the
patients analyzed were administered small doses of opioids by doctors,
not sent home with bottles of prescription pills.
Eventually, the paragraph of findings became known simply as “Porter and Jick.” The nickname only made things worse.
“That shorthand, in turn, lent prestige to the tiny thing and the claim
attributed to it: that less than 1 percent of patients treated with
narcotics developed addictions to them,” Quinones writes.
By the 1990s, the letter had become a “foundation for a revolution in
U.S. medical practice,” according to Dreamland. Researchers were urged
to “consider the work” of Porter and Jick. A Scientific American article
mentioned the pair’s “extensive study.” A registered nurse referred to
it as “gospel.” And in 2001, Time magazine called it a “landmark study”
showing that fears of addiction were “basically unwarranted.”
A key reason the letter was misinterpreted had to do with the New
England Journal of Medicine’s archives, according to “Dreamland.” None
of the journal’s material before 1993 was available online until 2010.
So when the letter was cited, it had the appearance of being a
peer-reviewed study, not a terse letter to the editor meant only to
stimulate conversation among fellow researchers.
Jick went on to do a broad range of other scholarly work. And, as he
told the Associated Press, he once testified as a witness for the
government in a lawsuit involving the marketing of painkillers. He was
apparently unaware for some time of what his short letter had triggered.
“It’s an amazing thing,” Jick said, according to “Dreamland.” “That
particular letter, for me, is very near the bottom of a long lit of
studies that I’ve done. It’s useful as it stands because there’s nothing
else like it on hospitalized patients. But if you read it carefully, it
does not speak to the level of addiction in outpatients who take these
drugs for chronic pain.”