Untoward Influence on Opioid Non-Addiction

"It was critical to the genesis and propagation of the crisis."
"The key thing about this paper ... is that it was leveraged to destigmatize opioid use."
Dr. David Juurlink, clinical toxicologist, Sunnybrook Health Sciences Centre, Toronto

"It really is a very powerful illustration of what I think is the greatest scandal in modern medical history."
"This is a lesson. Thousands of people have died as a result of doctors' prescriptions."
Dr. Mel Kahan, addictions expert, Women's College Hospital, Toronto

One researcher says a 1980 letter to the New England Journal of Medicine "helped the opiate manufacturers convince front-line doctors that addiction is not a concern.”  (McMaster University via The Canadian Press file photo)

When scientific research or study articles get published in prestigious science journals, their influence is judged by the number of times other articles or researchers reference them in their own papers. And in 1980, an extremely brief research 'letter' published in the New England Journal of Medicine distinguished itself by an astonishing number of references. More than enough other researchers were sufficiently impressed by the simple assertion in the letter that opioids are not addictive to repeat that claim. And in that little story lies a sad deception and its sorry outcome.

A new Canadian study documents the citations, no fewer than 600 and counting, and the impression it has had, and relating to that impression the far-reaching effects the conclusion has enjoyed in transforming the way in which countless physicians reacted, impacting on millions of patients. Dr. Juurlink, lead author of the study emanating from the Institute for Clinical Evaluative Sciences in Toronto, zeroed in on the promotion of narcotic painkillers as a safe, effective treatment for people dealing with chronic, non-cancerous pain.

Those narcotics known and valued for their ability to mute pain in patients were once used specifically to treat patients suffering from terminal cancer. But since that innocent-seeming conclusion that drugs of that nature were safe because patients would not become addicted to them (perhaps, though not noted, because those patients' lives were ending, and while the opioids offered relief from unbearable pain, the opportunity for addiction among patients heading for death would not occur), prescribing physicians were lulled into complacency.

And at a time when OxyContin had entered the pain-management pharmacopoeia, the use of this class of medicines was popularized by a need to address constant pain plaguing some patients. Opioids became the pain management tool of huge popularity, with Canadians' use of the drugs second only to its consumption in the United States on a per-capita basis. Since that time of innocence when opioids were viewed as a useful and innocuous pain management tool, addiction and deaths due to overdose has reached epidemic status.

The New England Journal editor, Dr. Jeffrey Drazen, is not prepared to issue a mea culpa, arguing the problem was one of misinterpretation, although he is prepared to include a notice that the conclusion of non-addiction should now be viewed with caution. The Journal website will link the conclusion reached in the letter to the newly published study by Dr. Juurlink and his colleagues. "It's impossible to know what role this has had in the opioid epidemic. It's a very multi-faceted thing", he believes.

Yet the original article by Dr. Herschel Jick and a Boston University Medical Center colleague claimed "Addiction rare in patients treated with narcotics" after 11,882 patients without a history of drug-dependency who were prescribed at least one narcotic while hospitalized, resulted in only four instances of addiction outcome. That paper was referenced as evidence that opioids given to patients with chronic pain long-term, not just while in hospital, would result in pain relief without undue consequences.

"If  you read it carefully, it does not speak to the level of addiction in outpatients who take these drugs for chronic pain", Dr. Jick argued in defence of his paper not having taken into account that assessments were not taken on each patient. What the new Canadian study found was that in over 70 percent of instances where the letter was cited, it was done so in validation of addiction being a rare outcome in opioid-taking patients.

And although, in view of the current upsurge in opioid addictions, citations favouring opioids for their non-addictive quality have levelled off recently, a Korean study last year referenced the letter, emphasizing use of fentanyl for chronic pain. In 1994 an editorial in the journal Canadian Family Physician, distributed across the country to family doctors, cited the letter as being "persuasive" in its conclusion; evidence that opioids could safely be used over a long period without addiction ensuing.

Now it is well known through followp-up research that five to ten percent of patients prescribed opioid painkillers to deal with their chronic pain, become addicted. According to Dr. Juurlink that number is "staggering", taking into account the millions of people who have been prescribed the use of opioids.