How Misuse of a Single Paragraph Ended Up Killing 60,000 Americans Per Year

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June 21, 2017 | 153,836 views

Story at-a-glance

  • In 1980, a five-sentence-long letter to the editor was published in NEJM, noting that hospitalized patients with no history of addiction who were treated, short-term, with opioids rarely developed addiction
  • This letter has been cited more than 600 times, serving as the basis of misleading and inaccurate statements suggesting opioids have a very low risk of addiction when prescribed for pain
  • Eighty percent of articles citing this letter to the editor made no mention of the fact that this data pertained specifically to hospitalized patients receiving the drugs on a short-term basis

By Dr. Mercola

Opioid addiction is at an all-time high in the U.S., and according to many addiction specialists, pain and hopelessness are primary drivers of this burgeoning crisis.1 Limiting the availability of opioids and making overdose-reversal drugs and treatment for drug addiction more readily available are part of the answer. But it's not enough.

We have to take a much deeper look at the root of the problem. What is causing all this physical pain and emotional distress in the first place? Clearly, the U.S. health care system is grossly ineffective when it comes to addressing chronic health problems. Whether pain is promoting hopelessness or the other way around is difficult to ascertain, but the two appear to be closely intertwined and need to be addressed together.

Somehow or another, we need to refocus our efforts to create lives worth living, and improve access to and information about basic disease prevention, which begins with diet and basic lifestyle choices — the kind of information I've focused on with my newsletter and website.

That said, it's worth looking at how use of prescription opioids ended up getting so out of control. Doing so will reveal an oft-ignored truth: Drug companies may, and often do, promote drugs that do more harm than good. After all, drugs are profit centers, and drug companies are first and foremost beholden to their shareholders — not patients — who expect to make a decent profit from their investments.

To maximize sales, drug companies may hide information, misinform and/or outright lie about their medicines, and this is precisely what happened with narcotic painkillers.

The Paragraph That Spawned the Opioid Crisis

In 1980, a five-sentence-long letter to the editor was published in the New England Journal of Medicine (NEJM), one of the most prestigious medical journals in the world. Under the headline "Addiction Rare in Patients Treated With Narcotics," the short letter, written by Jane Porter, a graduate student at Boston University Medical Center, read:

"Recently, we examined our current files to determine the incidence of narcotic addiction in 39,946 hospitalized medical patients who were monitored consecutively. Although there were 11,882 patients who received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients who had no history of addiction.

The addiction was considered major in only one instance. The drugs implicated were meperidine in two patients, Percodan in one, and hydromorphone in one. We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction."

This turned out to be a letter with dire repercussions for millions of people in the decades to come. As noted in The Atlantic, this letter to the editor ended up being "so routinely mis-cited" it took on "a life of its own."2

"[NEJM] … is issuing a corrective. It's a new study3 … from a team led by David Juurlink at the University of Toronto that tracked how the five-sentence letter passed through the game of academic citation … to become evidence that opioids are safe for chronic pain. In fact, it said no such thing," The Atlantic notes.

"… Hershel Jick, a doctor at Boston University Medical Center, had a database of hospital records that he used to monitor side effects from drugs … Something, perhaps a newspaper article, got Jick interested in looking at addiction. So he asked a graduate student, Jane Porter, to help calculate how many patients in the database got addicted after being treated with pain medicines, and dashed off a letter to the [NEJM].

Its brevity was commensurate with the effort involved … But as it began to accrue citations, its findings also began to mutate. Porter and Jick had only looked at hospitalized patients in regimented settings, but that detail got lost in the push to prescribe opioids to patients at home — an entirely different scenario."

Drug Companies Latched on to Evidence That Wasn't

In the years to come, this letter to the editor (most letters do not undergo any kind of peer-review) became an oft-cited piece of evidence used by drug companies and pain specialists alike. In all, it's been cited more than 600 times since its publication, serving as the basis of misleading and inaccurate statements such as: "[P]ain population with no abuse history is literally at no risk for addiction," and "There have been studies suggesting that addiction rarely evolves in the setting of painful conditions."4

A remarkable 80 percent of the articles citing Jick's letter failed to include the facts that his data pertained specifically to hospitalized patients receiving the drugs on a short-term basis. You simply cannot assume that because a narcotic is safe to use in the short term under careful monitoring by hospital staff, it will be safe long-term, and without careful monitoring.

According to Juurlink, "It's difficult to overstate the role of this letter. It was the key bit of literature that helped the opiate manufacturers convince front-line doctors that addiction is not a concern."5

Purdue Pharma used it as the basis for its claim that opioid addiction affects less than 1 percent of patients treated with the drugs. In a recent interview with The Associated Press (AP),6 Jick said he was "mortified that that letter to the editor was used as an excuse to do what these drug companies did." He also clarified that his letter "only referred to people getting opioids in the hospital for a short period of time and has no bearing on long-term outpatient use."

Researchers and journalists were no better. While the findings detailed in the letter were exceptionally narrow and the "study" less than thorough, researchers and journalists started referring to it as "extensive," citing it as a "landmark report." In 2001, Time magazine reported:7

"Many physicians now concede that patients have been undermedicated for decades, suffering needlessly. One reason was concern that big doses of opiates could depress respiration, but a large part stemmed from an exaggerated fear that patients would become addicted.

This fear, which continues to hold sway over American medicine, is basically unwarranted. A landmark study … found that only four became addicted to the [narcotic] drugs they received as patients. 'You don't see cancer patients running around robbing shopping malls to support their habits,' notes Carr."

NEJM Issues First-Ever Warning on 40-Year-Old Editor's Note

Following the publication of Juurlink's investigation into the citation trail leading from Jick's letter to all manner of false claims, NEJM has now added an editor's note to the 1980 letter,8 saying, "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."

NEJM editor, Dr. Jeffrey Drazen, explained his note to AP, saying, "People have used the letter to suggest that you're not going to get addicted to opioids if you get them in a hospital setting. We know that not to be true."9 The journal has also added a link from Jick's letter to Juurlink's new study — a move that should eliminate most misuse in the future. As noted by Juurlink:10

"In conclusion, we found that a five-sentence letter … 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.

In 2007, the manufacturer of OxyContin and three senior executives pleaded guilty to federal criminal charges that they misled regulators, doctors and patients about the risk of addiction associated with the drug. Our findings highlight the potential consequences of inaccurate citation and underscore the need for diligence when citing previously published studies."

60,000 Americans Overdosed in 2016

Opioid addiction and accidental overdoses are now taking a tremendous toll. According to U.S. Deputy Attorney General Rod Rosenstein, drug overdoses are now the leading cause of death among Americans under the age of 50!11 In 2015, more than 52,000 Americans died from some form of drug overdose; 33,000 of them involved some form of opioid.

Preliminary data for 2016 reveals that death toll is anywhere from 59,000 to 65,000.12 That's a 19 percent increase in one year, and the largest annual increase of drug overdose deaths in U.S. history. Between 2014 and 2015, drug overdose deaths rose by 11 percent.13 The most common drugs involved in prescription opioid overdose deaths include14 methadone, oxycodone (such as OxyContin®) and hydrocodone (such as Vicodin®).

Synthetic opioids like fentanyl are also being abused by a rising number of people. A recent article in The New York Times15 highlights the tragedy of Grant Seaver and Ryan Ainsworth, two 13-year-olds who died after taking the synthetic opioid U-47700, also known as "pinky." They got the drug from a teenage friend who had bought it on the dark web using bitcoin.

The sheer potency of synthetic opioids make them ideal for mailing. A standard envelope can hold enough fentanyl to get 50,000 people high. And, while the dark web marketplace Silk Road was shut down in 2013, others have popped up in its place, allowing people who might otherwise not have access to narcotics get them through the mail.

Disturbingly, rising fentanyl addiction also poses novel risks to first responders, law enforcement and even drug-sniffing dogs. The drug is so potent (anywhere from 500 to 1,000 percent more potent than morphine) that inhaling just a few flakes can be lethal.

In Ohio, a police officer nearly died from exposure to a fentanyl-related compound. During a routine traffic stop, he noticed a bag of white powder in the car. He used gloves and a mask for protection at the scene, but didn't notice he'd gotten some on his shirt. Later, when a colleague pointed out the powder on his uniform, he brushed it off with his bare hand.

An hour later, he collapsed and had to be treated with FOUR doses of naloxone. He was lucky and survived the ordeal. Many fentanyl users are not. Deadly overdoses involving fentanyl rose by 50 percent between 2013 and 2014, and another 72 percent between 2014 and 2015.

Other Opioid Facts and Statistics

To truly understand the enormity of America's drug problem, consider the following:

Drug overdoses are the ninth leading cause of death in the U.S.

In 2015, 52,404 Americans died from drug overdoses; 33,091 of them involved an opioid and nearly one-third of them, 15,281, of them were by prescription.16,17,18 Meanwhile, kidney disease, listed as the ninth leading cause of death on the CDC's top 10 list, killed 48,146.19

The CDC does not include drug overdoses on this list, but if you did, drug overdoses (63 percent of which are opioids), would replace kidney disease as the ninth leading cause of death as of 2015, inching its way toward the eighth slot, currently occupied by respiratory complications such as pneumonia, which took 55,227 lives in 2015. As noted earlier, in the 50-and-younger demographic, drug overdoses are now the No. 1 cause of death.20

Opioid use has overtaken smoking

More Americans now use prescription opioids than smoke cigarettes.21 One in 4 Americans (and 1 in 3 millennials) reports knowing someone addicted to opioids.22

Opioids kill more Americans than car crashes

In 2014, prescription drug overdoses, a majority of which involved some type of opioid, killed more Americans than car crashes (49,714 compared to 32,675).23 This held true for 2015 as well, despite 2015 being hailed as the deadliest driving year since 2008. In all, 38,300 Americans died in car crashes in 201524 — a sharp rise thought to be related to a combination of cheaper gas prices and hence increased travel, and using smartphones while driving.25

Drugged driving causes more fatal crashes than drunk driving

Driving under the influence of opioids and other drugs has become a serious problem, now causing more fatal car crashes than drunk driving.26 Prescription and/or illegal drugs were involved in 43 percent of fatal car crashes in 2015, while 37 percent involved illegal amounts of alcohol.

Opioids, specifically, can increase your risk of being involved in a car crash by a factor of 10, having a relative car crash risk between 2 and 10.27 (A driver with no drugs or alcohol in their system has a relative crash risk of 1.)

Americans use 80 percent of global opioid supply

Prescriptions for opioid painkillers rose by 300 percent between 2000 and 2009,28,29 and Americans now use 80 percent of all the opioids sold worldwide.30 In Alabama, which has the highest opioid prescription rate in the U.S., 143 prescriptions are written for every 100 people.31

Financial cost of opioid addiction tops $193 billion annually

Addiction to opioids and heroin now costs the U.S. more than $193 billion each year.

Prenatal exposure is rampant

Despite carrying risks of pregnancy-related problems and birth defects, nearly one-third of American women of childbearing age are prescribed opioid painkillers32 and more than 14 percent of pregnant women were prescribed opioids during their pregnancy.33

Addiction affects more than 1 in 4 opioid users

Studies show addiction affects about 26 percent of those using opioids for chronic non-cancer pain, and 1 in 550 patients on opioid therapy die from opioid-related causes within 2.5 years of their first prescription.34

Opioid addiction has lowered life expectancy in U.S.

According to the latest data from the National Center for Health Statistics, life expectancy for both men and women dropped between 2014 and 2015, for the first time in two decades, and overdose deaths appear to be a significant contributor.35,36,37

Prescription painkillers are the No. 1 gateway to heroin

OxyContin and other opioid pain killers have been identified as the primary gateway drugs to heroin.38 Chemically, these drugs are very similar and provide a similar kind of high. According to a 2013 U.S. Substance Abuse and Mental Health Services Administration report, nearly 80 percent of people who use heroin have previously used prescription painkillers.39

Opioid use and addiction found to have lifelong health ramifications

According to Dr. Scott Krakower, assistant unit chief for psychiatry at Zucker Hillside Hospital in New York, opioids cause changes in your brain that can increase your risk of depression, and the effects may be "long-lasting or even permanent."40

Opiates depress your central nervous system and slow the electrical activity in your brain, which can result in circadian rhythm disruptions, mood changes and cognitive decline. Opiate use also promotes41 bowel dysfunction, endocrine system (hormonal) problems, sexual dysfunction, reduced fertility, reduced testosterone levels in men and bone disorders.

Drug Industry Responsible for Mass Addiction Now Tries to Cash in on It

Many believe the drug companies that create and sell opioids need to be held accountable for America's drug problem, especially since several have been caught lying about the benefits and risks of their drugs. As noted by the Organic Consumers Association,42 the drug industry has "fostered the opioid addiction epidemic" by:

Now, adding insult to injury, drug companies are trying to cash in on the opioid addiction crisis by pushing for legislation to combat the epidemic with, you guessed it, other drugs. NPR recently reported how Alkermes, a company that makes the anti-addiction medication Vivitrol — a monthly injection that costs about $1,000 per shot — is trying to weasel its drug into state laws, making it the sole treatment recommended for opioid addiction. NPR writes:44

"Two years ago, a mental health advocate named Steve McCaffrey stood at a podium in the Indiana statehouse, testifying in favor of an addiction treatment bill … His brief testimony appeared straightforward. 'We rise in support, urge your adoption,' said McCaffrey. He said the legislation would move the state 'toward evidence-based treatment.' But the bill wouldn't do that.

Instead, it would cement rules making it harder to access certain addiction medications — medications that many patients rely on. The goal was to steer doctors toward a specific brand-name drug: Vivitrol … State Rep. Steve Davisson, the bill's sponsor, says McCaffrey helped write the bill … But there was something important that Davisson and other lawmakers didn't know about him.

State lobbying records show that McCaffrey lobbies for Alkermes, the company that makes Vivitrol …  McCaffrey's work … is part of a larger pattern … [I]n statehouses across the country, and in Congress, Alkermes is pushing Vivitrol while contributing to misconceptions and stigma about other medications used to treat opioid addiction …

While policymakers are grasping for solutions to the nation's opioid epidemic, Alkermes … is using policy to promote its drug and, in some cases, hamper access to medications that can help. And in so doing, it's looking to turn its drug into a blockbuster."

Industry Regulations Hamper Legal Recourse

A growing number of U.S. states,45 counties and even individual cities have filed lawsuits against opioid manufacturers for their role in creating the addiction crisis. Unfortunately, it's proving to be extremely difficult to hold drug companies accountable for their actions. As reported by Reuters,46 "The industry's highly regulated nature could pose a hurdle to their success." Since opioids, like all drugs, are regulated by the U.S. Food and Drug Administration (FDA), drug companies simply lean on the drugs' FDA approval.

"In their view, judges and juries could defer to the agency's approval of the companies' opioid products as safe and effective for treating chronic pain and of the drugs' warning labels that disclosed addiction-related risks," Reuters notes.

"Carl Tobias, a professor at Richmond School of Law, said FDA-approved warning labels and the role of doctors in prescribing medication can insulate pharmaceutical companies from liability for failing to warn of a drug's risks. But he noted Ohio's lawsuit claimed the companies used advertising in medical journals and marketing presentations to downplay the risks of opioids.

In announcing the lawsuit, Ohio Attorney General [Mike] DeWine argued the drugmakers' deception continued 'despite the warnings in the small print of their very own drug labels and package inserts which clearly contradict their marketing.' 'You can give a great warning but undercut it, and that can go to the fraud point,' Tobias said."

Drug companies are also arguing that state and local governments should not be allowed to use private lawyers when filing these kinds of lawsuits against them. Private attorneys typically receive a percentage of the settlement, and drug companies have argued that hiring private lawyers rather than using public servants violates their constitutional rights to due process. This ridiculous argument has already worked once.

Last year, a judge invalidated the law firm Cohen Milstein Sellers & Toll's agreement to represent former New Hampshire Attorney General Joseph Foster in his lawsuit against Actavis Pharma, Endo Pharmaceuticals, Janssen Pharmaceuticals, Purdue Pharma and Teva Pharmaceuticals.47 The ruling effectively prevented the state from filing suit, since no "public servants" with the prerequisite legal skills are available to run the case.

Are You or Someone You Love Addicted to Painkillers?

This is a Flash-based audio and may not be playable on mobile devices.

Anyone can get hooked on opioids. It doesn't matter where you live or how great a family you came from. STAT News' special report, "52 Weeks, 52 Faces" features obituaries of people who lost their lives to opioid addiction. You'd be hard-pressed to "peg" any one of them as a drug addict.

Some marketing materials for opioids still claim the drug will not cause addiction "except in very rare cases," describing the adverse effects patients experience when quitting the drug as a "benign state" and not a sign of addiction. This simply isn't true. Panic is one psychological side effect commonly experienced when quitting these drugs, and this can easily fuel a psychological as well as physical dependence on the drug.

It's important to recognize the signs of addiction, and to seek help. If you've been on an opioid for more than two months, or if you find yourself taking higher dosages, or taking the drug more often, you're likely already addicted and are advised to seek help from someone other than your prescribing doctor. Resources where you can find help include:

With all the health risks associated with opioid painkillers, I strongly urge you to exhaust other options before resorting to these drugs. For a long list of alternative pain treatments, please see my previous articles, "Treating Pain Without Drugs," and "New Treatment Guidelines for Back Pain Stress Non-Drug Interventions."

[+]Sources and References [-]Sources and References

  • 1 Washington Post December 29, 2016
  • 2, 45 The Atlantic June 2, 2017
  • 3, 10 NEJM 2017; 376:2194-2195
  • 4, 6, 9 STAT News May 31, 2017
  • 5 NBC News June 1, 2017
  • 7 Time Magazine June 24, 2001
  • 8 Retraction Watch June 2, 2017
  • 11, 20 CNS News June 7, 2017
  • 12 New York Times June 5, 2017
  • 13 Newsy.com December 18, 2016
  • 14, 17 CDC Prescription Opioid Overdose Data
  • 15 New York Times June 10, 2017
  • 16 CDC Morbidity and Mortality Weekly Report December 30, 2016 / 65(50-51);1445–1452
  • 18 Washington Post April 2, 2017
  • 19 The New York Times September 11, 2012
  • 20 Archives of Internal Medicine 2012 Oct 22; 172(19): 1444-53
  • 21 Scientific American, Surgeon General Report Tackles Addiction
  • 22 Pain Medicine 2016; 17(7): 1353-1375
  • 23 Forbes November 17, 2016
  • 24 National Safety Council February 17, 2016
  • 25 Newsweek August 17, 2015
  • 26 MSN.com April 27, 2017
  • 27 Governors Highway Safety Association and the Foundation for Advancing Alcohol Responsibility, “Drug-Impaired Driving” (PDF)
  • 28 Drugabuse.gov May 14, 2014
  • 29 Time Magazine July 31, 2014
  • 30 Aplus.com April 19, 2016
  • 31 NPR.com July 1, 2014
  • 32 Kaiser Health News January 22, 2015
  • 33 American Society for Anesthesiologists February 12, 2014
  • 34 New England Journal of Medicine 2016; 374:1501-1504
  • 35 New York Times December 8, 2016
  • 36 STAT News December 8, 2016
  • 37 Washington Post December 8, 2016
  • 38 USA TODAY April 15, 2013
  • 39 WebMD February 11, 2014
  • 40, 41 CNN December 28, 2016
  • 42 Organicconsumers.org May 2, 2016
  • 43 LA Times May 5, 2016
  • 44 NPR June 12, 2017
  • 46 Reuters June 2, 2017
  • 47 Legal News Online February 17, 2016
  • 48 Substance Abuse Mental Health Service Administration (SAMHSA)