In 1980, a pair of doctors published a brief letter in the New England Journal of Medicine. Spanning a total of five sentences, the letter claimed, with little substantial evidence, that the development of addiction was very rare in hospitalized patients who briefly received opioids and had no prior history of addiction.
Drugmakers quickly latched onto the letter, fueling the beginning of the opioid epidemic — to the point that the results have horrified one of the letter’s authors. “I’m essentially mortified that that letter to the editor was used as an excuse to do what these drug companies did,” Hershel Jick told the Associated Press. “They used this letter to spread the word that these drugs were not very addictive.”
Now a new study in the NEJM has looked at just how much of a reach the letter had.
Researchers Pamela Leung, Erin Macdonald, Irfan Dhalla, and David Juurlink found that the letter was cited more than 600 times since it was published, with a sharp increase after the opioid maker Purdue Pharma introduced OxyContin in the mid-1990s.
The researchers concluded, “[W]e found that a five-sentence letter published in the Journal in 1980 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 by helping to shape a narrative that allayed prescribers’ concerns about the risk of addiction associated with long-term opioid therapy.”
Juurlink further elaborated on his findings in a series of tweets shortly after his NEJM piece was published. He pointed out that even though the letter was a mere five sentences, some of the people citing the letter didn’t appear to actually read it.
The citations often claimed, for example, that the letter found zero cases of addiction among patients with no prior history of addiction — when the letter cited four cases. And the citations often argued that the findings proved that opioid painkillers could be prescribed safely in an outpatient setting — when the letter, as one author told the Associated Press, only looked at hospital patients who briefly received opioids, and its findings couldn’t be extrapolated to opioids’ long-term use in an outpatient setting.
Juurlink and his team aren’t the first to draw the connection between the opioid crisis and the 1980 letter. It was a focus of Sam Quinones’s Dreamland, a groundbreaking book highlighting the opioid epidemic and its causes.
But the new study shows how prominent the letter was: With hundreds of citations, it quickly became instrumental in spreading the myth that opioids could be prescribed safely without the risk of addiction. Decades later, the opioid epidemic is the deadliest drug overdose crisis in US history.
The opioid epidemic, explained
In 2015, more Americans died of drug overdoses than any other year on record — more than 52,000 deaths in just one year. That’s higher than the more than 38,000 who died in car crashes, the more than 36,000 who died from gun violence, and the more than 43,000 who died due to HIV/AIDS during that epidemic’s peak in 1995.
This latest drug epidemic, however, is not solely about illegal drugs. It began, in fact, with a legal drug.
Back in the 1990s, doctors were persuaded to treat pain as a serious medical issue. There’s a good reason for that: About one in three Americans suffer from chronic pain, according to a 2011 report from the Institute of Medicine.
Pharmaceutical companies took advantage of this concern. Through a big marketing campaign, they got doctors to prescribe products like OxyContin and Percocet in droves — even though the evidence for opioids treating long-term, chronic pain is very weak (despite their effectiveness for short-term, acute pain), while the evidence that opioids cause harm in the long term is very strong.
So painkillers proliferated, landing in the hands of not just patients but also teens rummaging through their parents’ medicine cabinets, other family members and friends of patients, and the black market.
As a result, opioid overdose deaths trended upward — sometimes involving opioids alone, other times involving drugs like alcohol and benzodiazepines (typically prescribed to relieve anxiety). By 2015, opioid overdose deaths totaled more than 33,000 — close to two-thirds of all drug overdose deaths.
Seeing the rise in opioid misuse and deaths, officials have cracked down on prescriptions painkillers. Law enforcement, for instance, threatened doctors with incarceration and the loss of their medical licenses if they prescribed the drugs unscrupulously.
Ideally, doctors should still be able to get painkillers to patients who truly need them — after, for example, evaluating whether the patient has a history of drug addiction. But doctors, who weren’t conducting even such basic checks, are now being told to give more thought to their prescriptions.
Yet many people who lost access to painkillers are still addicted. So some who could no longer obtain prescribed painkillers turned to cheaper, more potent opioids: heroin and fentanyl, a synthetic opioid that’s often manufactured illegally for nonmedical uses.
Not all painkiller users went this way, and not all opioid users started with painkillers. But statistics suggest many did: A 2014 study in JAMA Psychiatry found many painkiller users were moving on to heroin, and a 2015 analysis by the Centers for Disease Control and Prevention found that people who are addicted to prescription painkillers are 40 times more likely to be addicted to heroin.
So other types of opioid overdoses, excluding painkillers, also rose.
That doesn’t mean cracking down on painkillers was a mistake. It appeared to slow the rise in painkiller deaths, and it may have prevented doctors from prescribing the drugs to new generations of people with drug use disorders.
But the likely solution is to get opioid users into treatment. According to 2014 federal data, at least 89 percent of people who met the definition for a drug use disorder didn’t get treatment. Patients with drug use disorders also often complain of weeks- or months-long waiting periods for care.
Some states, such as Louisiana and Indiana, have taken a "tough on crime" approach that focuses on incarcerating drug traffickers. But the incarceration approach has been around for decades — and it hasn’t stopped massive drug epidemics like the current crisis.