A single letter, five sentences long, that appeared in the influential New England Journal of Medicine in 1980 helped spark America's opioid crisis, according to a new analysis announced this week by researchers in Toronto. Appropriately, the new analysis also appears as a letter in the NEJM.
The authors argue that this letter — or rather a widespread misreading of the letter — contributed directly to a general belief that popular opioid painkillers were not very addictive. They also note that more than 183,000 U.S. deaths were attributed to prescription opioids from 1999 to 2015.
The original letter, written by two doctors at Boston University, reported on research they had conducted of nearly 12,000 cases in which hospitalized patients had received narcotic painkillers in the hospital. In only four cases was there evidence of resulting addiction, if the patient had no previous addiction.
A letter published in the New England Journal of Medicine in 1980 created false confidence that opioid addiction was rare. | Screenshot, New England Journal of Medicine
But the letter was widely understood to mean that the drugs were not highly addictive at all, even if they were placed in consumers hands at a pharmacy instead of administered by doctors in a hospital.
The problem began with the letter's headline, which read, "Addiction rare in patients treated with narcotics."
But while the headline was arguably sloppy, the error didn't lie with the text of the original letter. The problem lay with hundreds of people who misread it, or perhaps simply read the headline in the following decades, whether innocently or willfully. This included many who ought to have known better.
The new study analyzed over 600 articles that cited this letter since its publication, and found that nearly 500 of those citations neglected to mention that the patients studied were administered the narcotics by doctors in the hospital, not given pills to take home.
"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," The Washington Post notes. "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."
Drug companies that relied on this letter to reassure skeptical doctors and consumers may soon be explaining themselves in court.
Ohio is now suing five pharmaceutical companies for deceiving consumers and prescribing doctors about the addiction risks of their drugs. Ohio Attorney General Mike DeWine said in a statement that his "lawsuit alleges that the drug companies engaged in fraudulent marketing regarding the risks and benefits of prescription opioids which fueled Ohio's opioid epidemic."
The Ohio lawsuit is reminiscent of tobacco litigation led by state attorneys general. In 1998, 46 states reached a settlement with the four largest tobacco companies, made possible by evidence that emerged showing that the industry consciously manipulated nicotine levels and hid knowledge of its addictive qualities.