The New England Journal of Medicine startled everyone this week by a posting a one-sentence warning over the so-called Porter & Jick letter to the editor that the journal published in January of 1980.
The warning note 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.”
I find it remarkable that the NEJM did this, particularly so long after the letter itsel
f was published in the journal. Apparently this kind of note is very rare.
But I think it confirms what I wrote in Dreamland – in which I interviewed the main author of the letter, Dr. Herschel Jick.
I think it’s important to reiterate the impact, as well as the intent, of the letter.
As written, it is entirely correct. That a data base of hospital patient records, that Dr. Jick ran, and still runs, found the following: of 11,800 patients given narcotic painkillers while in hospital, only four developed an addiction to those drugs.
Remember this was data taken from the 1960s and 1970s, a time when narcotic painkillers were rigorously controlled, and never given to patients to take home with them. So it stands to reason that patients, under such strict controls and administered the drugs only in hospital, would rarely develop addictions – as the letter’s headline in the journal read when it was published: Addiction Rare in Patients Treated With Narcotics.
They simply didn’t have access to large supplies of narcotics, and especially drugs to take home with them, as patients routinely do today. Hence they didn’t run much risk of addiction. (The whole thing, btw, helped change my mind about what ignites a scourge of addiction, which I now believe is not demand, but supply. Supply first sparks demand.)
The problem came not with how the letter was written, but how it was interpreted, then used, by others. Through the late 1980s and 1990s, it was widely cited, quoted, footnoted – as my research in Dreamland made clear and as a recent letter to the NEJM from the Canadian doctors confirmed. It was deemed to be proof that somehow science now knew that addiction was rare when opiates were used to treat pain. Through the years, it became known, through a process similar to a game of telephone, as some kind of “landmark study” that presumably refuted much about what we know about narcotic painkillers and addiction.
The Porter & Jick letter – 101 words – neither did, nor intended, anything of the kind.
It was also used, of course, by pharmaceutical companies – especially Purdue Pharma, manufacturer of OxyContin – as proof that their drugs no longer caused addiction when they were used to treat pain. The company used the statistic that “less than 1 percent” of all patients administered opiate painkillers drugs – especially OxyContin – grew addicted to it. This was not true nor supported by any science. It was not supported by Porter & Jick, which was making an entirely different observation. Yet the letter was used to convince a generation of doctors that science now knew new things about narcotic painkillers and one was that they were “virtually nonaddictive” when used to treat pain. A claim that, again, has no basis in science or the letter.
All this I wrote in Dreamland, which came out two years ago. I found the whole story to be an unsettling episode in how scientific thinking changes based on no evidence at all, but due instead to deft and relentless marketing.
I’ll add one more thing. The NEJM’s warning note was prompted, as I said, by a review of the letter and its influence in scholarly studies that was published by some Canadian doctors in the journal this week.
I read the letter these doctors wrote and I don’t see Dreamland credited or footnoted.
I’m trying to take it all in with equanimity. Yet I’ll admit to some frustration to have done so much research and storytelling that brought this to light as part of Dreamland’s larger story of how this opiate-addiction epidemic spread, and which others have read and learned from, and then not have it reflected in the work those people do. On the contrary, the Canadian doctors’ letter is presented as some new revelation, which it is not.
So I’ll just say that it would have been nice to see my work credited in the recent NEJM report by those Canadian doctors, as well as media coverage of that letter. I’ll leave it at that.
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Physicians are insular and are frequently unethical. They will rarely if ever accept that a non-physician and a journalist will uncover any new medical knowledge. Acknowledging your work would be admitting that they got medical knowledge wrong a lay person called them out on it. So they will not acknowledge you. I have often heard physicians say that the smartest people in the US become physicians. This attitude is endemic to their community.
Agree Sam…they should have noted your work..,DREAMLAND is solid …I’m finishing it now
I’ll give you and Dreamland credit for highlighting a NEJM note that help ignite and fuel the Dr prescribed opioat epidemic (for what it worth) since I read it there first.
I just finished reading “Dreamland.” I admire the amount of research you did. Great story telling. So painful to read yet I was riveted and fascinated to learn more. Well done, Sir.
Mr. Quinones, please check your email from me. With regard to the term “abuse deterrent” referring to newer generation opioids that are more crush proof, etc (by the way Oxycontin is an abuse deterrent medication), I am trying to prevent yet another wave of the opioid epidemic. The term “abuse deterrent” could easily be misconstrued by physicians/patients/companies to mean drug abuse deterrent; these drugs are still opioids and carry the same addiction potential – they are just potentially less likely to be crushed and snorted or injected because of their physical properties (excluding Oxycontin, of course). I await your response to my request. Thank you for all that you have done and continue to do for victims of the opioid epidemic. I, for one, credit your work for allowing all of us to piece together all of the details of the epidemic and am truly appreciative!
Hola Sam, Yes, the New England Journal of Medicine journal should have cited your work, DREAMLAND, hands down, no question. It is an an appalling oversight on their part.
Your book is one of the most important published about the drug war and the narcotrafficking Mexico ever, anywhere, anytime. And when I reviewed your book for LITERAL magazine I said so, and I took special care to highlight the Porter and Jick letter boondoggle that you write about in DREAMLAND.
Excerpt from my review:
“Enter Purdue Pharma with its new painkiller, OxyContin, an opium derivative with a molecular structure similar to heroin. Somehow in all the hoopla, Porter and Jick’s letter to the editor of the New England Journal of Medicine— not a report, and certainly not a study, but a mere one-paragraph note that less than one percent of hospitalized patients receiving opiates for pain became addicted— “had become a foundation for a revolution in U.S. medical practice.” It seems few troubled to read said letter; armies of sales reps marched out citing “Porter and Jick” and—magic gong— the New England Journal of Medicine. As one nurse told Quinones, “Everybody heard it everywhere. It was Porter and Jick. We all used it. We all thought it was gospel.”
If anyone wants to see that review it is at this link:
http://literalmagazine.com/dreamland-the-true-tale-of-americas-opiate-epidemic/
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Your book certainly changed my way of thinking! Best we can do is share and spread your message.
I just read the recent report from the FDA Commish: “More Forceful Steps on Epidemic of Opioid Addiction.” http://nationalpainreport.com/fda-commish-more-forceful-steps-on-epidemic-of-opioid-addiction-8833702.html Talk about using flawed data to justify their agenda. I urge you to read this article and then read the studies they sight as proof. According to data from CDC and SAMHSA, nearly 2 million Americans abused or were dependent on prescription opioids in 2014, and more than 1,000 people are treated in emergency departments each day due to misusing prescription opioids. http://jamanetwork.com/journals/jamapsychiatry/fullarticle/1874575 How they can reach the conclusions they did from this study is beyond me. Considering 705 out of 2139 people responded, it was done at 12 outpatient clinics in PA. In the study 39.3% of people had previously used illicit drugs, and 22.5% had a history of substance abuse treatment. What kind of sample is this? How can you draw conclusions from such a small, convoluted group? The study is blown way out of proportion. Of the 1000 a day who are in the ER because of misuse of opioids in 2014, the study sighted went up to 2011 and states that opioid visits to the ER were 420,040 for 2011. That comes out to 1151 a day but divide that into a population of 350,000,000+M and it seems minuscule. The CDC and FDA are also creating data and using it to fit their agenda.
Then there is the data they used to write the 2016 CDC Guidelines that their own peer reviewers said was poor and weak. Now that these “Guidelines” are taken as gospel by the VA, Medicare, Medicaid and chronic pain patients who have never abused opioids are being dropped by doctors who will no longer prescribe opioids, and opioid medications are withdrawn that have worked for years with these people committing suicide as they cannot stand the pain. Was it the intention of the FDA and CDC to rid our country of these patients? If so, it reminds one of Nazi Germany where those deemed a burden on society were euthanized. Is this where we are going as a country? How about Trumpcare? Cut Medicare, Medicaid, SS Disability. Is this the beginning of health care only for those who can afford it and are considered an asset to society?
Sam,
You clearly connected the dots in Dreamland showing the history of this horrible public health disaster that was caused by big pharma and corrupt or ignorant physicians , many in the pockets of drug companies. Your book was very well researched. The recent article in NEJM about the Jick letter is fascinating! How a simple letter was misconstrued into something it wasn’t.
Exactly. Keep up the good fight Sam–we’re with you!
yes attribution seems to have died with print