A one-paragraph letter, barely a hundred words long, unwittingly became a major contributor to today's opioid crisis, researchers say.
"This has recently been a matter of a lot of angst for me," Dr. Hershel Jick, co-author of that letter, told Morning Edition host David Greene recently. "We have published nearly 400 papers on drug safety, but never before have we had one that got into such a bizarre and unhealthy situation."
The letter, published in the New England Journal of Medicine in 1980, was headlined "Addiction Rare in Patients Treated With Narcotics." Written by Jick and his assistant Jane Porter of the Boston Collaborative Drug Surveillance Program at Boston University Medical Center, it described their analysis of hospitalized patients who had received at least one dose of a narcotic painkiller. Among the nearly 12,000 patients they looked at, they found "only four cases of reasonably well documented addiction in patients who had no history of addiction." Their conclusion was that despite widespread use of narcotics in hospitals, addiction was rare in patients who had no history of addiction.
Inaccurate representations of that 1980 letter led to a dramatic increase in the prescribing of opioids for chronic pain, according to an article published this month in the same medical journal by Dr. David Juurlink of the University of Toronto, who researches drug safety. He and his co-authors found more than 600 citations of the letter, a majority of which failed to note that the patients whom Jick and Porter described were in hospitals for brief stays when prescribed opioids. Some of the citations "grossly misrepresented the conclusions of the letter," they found.
"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," they write, pointing out that citations soared after the introduction of OxyContin in the mid-1990s.
Jick says that when the letter was published in 1980, it was almost inconsequential. "Only years and years later, that letter was used to advertise by new companies that were pushing out new pain drugs," he says. "I was sort of amazed. None of the companies came to me to talk to me about the letter, or the use as an ad."
He says the drug companies used his letter to conclude that their new opioids were not addictive. "But that's not in any shape or form what we suggested in our letter."
Asked whether he regrets having written the letter, Jick says, "The answer is, fundamentally, sure. The letter wasn't of value to health and medicine in and of itself. So if I could take it back — if I knew then what I know now, I would never have published it. It wasn't worth it."
Morning Edition editor Steve Tripoli contributed to this story.
DAVID GREENE, HOST:
Let's hear from a doctor who may have inadvertently helped launch America's opioid epidemic.
HERSHEL JICK: This has recently been a matter of a lot of angst for me.
GREENE: Dr. Hershel Jick's 1980 letter to the editor in the New England Journal of Medicine was only a hundred words long. The letter said that patients receiving small doses of opiates for acute pain, closely supervised in hospitals, had little risk of addiction.
JICK: It was almost totally inconsequential at the time. And only years and years later, that letter was used to advertise by new companies that were pushing out new pain drugs.
GREENE: Yeah. This month, 37 years later, the New England Journal of Medicine added an editor's note. It said Hershel Jick's long-ago letter was wrongly cited hundreds of times to justify prescribing opioids for longer-lasting, chronic conditions. Dr. Jick told me that was never his intent.
So you were looking at and, I guess, concluded that addiction was pretty rare among patients hospitalized who got opioids.
JICK: That's exactly what it was. They were sitting in the hospital. They had no prior history of addiction. And under those circumstances, with those drugs that were around there, it was rare to come on while they're in the hospital.
GREENE: You're saying that there's a difference between when you receive these drugs in the hospital versus as an outpatient or treating, you know, chronic pain over months and years.
JICK: The people are completely different. People who get addicted or addicted on the outside - they have a lot of chronic pain or they somehow get hooked or whatever.
GREENE: So when did you first realize that your letter was being cited in the drug industry?
JICK: I was sort of amazed. None of the companies came to me to talk to me about the letter or the use as an ad. And I suddenly realized that there was this big thing going on. And if you believe the New England Journal, this was all blamed on that seven-line letter to the editor.
GREENE: Do you think they're right? I mean, this was really a revolution in medicine in many ways - using opioids to treat pain. Do you think your letter played this big a role?
JICK: I have no idea how big a role it should've played, but it was used by drug companies who created these new opioids and concluded that they were not addictive. But that's not in any shape or form what we suggested in our letter.
GREENE: And how do you feel about that?
JICK: Well, to be honest, I'm mortified because we have published roughly 400 papers on drug safety. But never before have we had one that got into such a bizarre and unhealthy situation.
GREENE: I mean, obviously, you did not intend for these drug companies to ever use it as an ad, but now that you know what a disaster this has been - the number of addictions and number of deaths - I mean, do you have any regrets about writing those words at all?
JICK: Well, the answer is, fundamentally, sure. You know, the letter itself wasn't of value to health and medicine in and of itself. So if I could take it back - if I knew then what I know now - I would never have published it. It wasn't worth it.
GREENE: Dr. Jick, thank you so much for taking the time to talk to us. We appreciate it.
JICK: Thank you.
GREENE: Dr. Hershel Jick is director emeritus of Boston University's School of Public Health. Transcript provided by NPR, Copyright NPR.