1980 NEJM Letter the Genesis of the Opioid Crisis?

Deborah Brauser

June 06, 2017

The now infamous "Porter and Jick" letter published in the New England Journal of Medicine (NEJM) in 1980, which has been cited more than 600 times over the years, may have been the spark that ignited North America's opioid crisis, new research suggests.

The original, one-paragraph letter was written by principal investigator Herschel Jick, MD, Boston University Medical Center, Waltham, Massachusetts, and his assistant and lead author, Jane Porter.

In just five sentences, the duo reported that among 39,946 hospitalized medical patients, of whom 11,882 received at least one narcotic, there were only four documented cases of addiction – and only one of these cases was considered major.

The letter ended by stating, "the development of addiction is rare in medical patients with no history of addiction."

A new Correspondence piece published in the June 1 issue of the NEJM reports that although the letter was not heavily referenced, it has been cited more than 600 times, with many authors "grossly misrepresenting" the conclusion.

"It's hard to overstate how important this letter was to the ensuing opioid crisis," corresponding author David N. Juurlink, MD, PhD, Sunnybrook Research Institute, Toronto, Ontario, Canada, told Medscape Medical News.

In a recent interview with the Associated Press that was published in the Washington Post, Dr Jick said his letter was never intended to be used the way it has been. "I'm essentially mortified that that letter to the editor was used as an excuse to do what these drug companies did," he said in the interview.

Taken Out of Context

More than 183,000 deaths from prescription opioids occurred in the United States between 1999 and 2015, report Dr Juurlink and colleagues.

"The crisis arose in part because physicians were told that the risk of addiction was low when opioids were prescribed for chronic pain," they write.

According to the Washington Post story, Dr Jick's original intent was just to report on short-term use of narcotics in their hospital setting. Their letter was never intended to weigh in on long-term use.

The controversy about the letter, commonly referred to as "Porter and Jick," was discussed in the 2015 book, Dreamland: The True Tale of America's Opiate Epidemic.

That Porter and Jick has been heavily cited "has been known for many years, with many of the citations overstating the conclusion, especially generalizing it to outpatients with chronic pain," said Dr Juurlink.

"What we wanted to do was examine every citation and characterize how each portrayed the original article," he added. "We suspected we would find the majority would essentially parrot the title ("Addiction Rare in Patients Treated With Narcotics"), and that's exactly what we found."

608 Citations

The investigators identified 608 citations of the original letter "and noted a sizable increase after the introduction of OxyContin...in 1995."

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.

Selected quotes pulled by the researchers from articles citing Porter and Jick include the following:

  • "This pain population with no abuse history is literally at no risk for addiction;"

  • "In reality, medical opioid addiction is very rare;" and

  • "...there have been studies suggesting that addiction rarely evolves in the setting of painful conditions."

"This article wasn't even available online until 2010. So until then, all you had was the title and that it was in the New England Journal of Medicine, one of the most prestigious journals in medicine," said Dr Juurlink.

"I think the title, the source journal, and the fact that it was largely hidden from those who didn't want to make a trip to the library went a long way towards allowing the article to be exploited by individuals seeking to destigmatize opioids for long-term pain. And a lot of those companies had drug-company money behind them."

"A Medical Curiosity"

The original letter is available in the journal's archives, albeit with a new note from the editor at the top warning that it has been "heavily and uncritically cited" in others' arguments that this type of addiction is rare.

Asked if he thinks this new note is enough, Dr Juurlink said, "I think what you're really asking is if the original letter should be retracted. And the answer to that is no.

"The letter doesn't matter anymore and is now a medical curiosity. Its contribution to the crisis was made long ago. I am glad that the journal has made it open access, and I think adding the note is about all they can do," he said.

"Even if we could snap our fingers and make the letter disappear, the horse has already left the barn."

Dr Juurlink and two of the other three authors report no relevant financial relationships. The remaining author has received personal fees from Health Quality Ontario outside the submitted work.

N Engl J Med. 2017;2194-2195. Full text

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