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How a one-paragraph letter helped fuel the opioid epidemic


A new study suggests a five-sentence correspondence published in The New England Journal of Medicine in 1980 was widely cited to downplay the risk of addiction during long-term treatment with opioid painkillers.

Entitled “Addiction rare in patients treated with narcotics,” the correspondence appeared as letter to the editor written by Dr. Jane Porter and Dr. Hershel Jick in 1980. It described an analysis of patients hospitalized at Boston University Medical Centre who were treated with opioids, and concluded that addiction was present in less than one per cent of patients. However, the brief letter offered no insight into how addiction was ascertained and did not examine the use of opioids for chronic pain in outpatients.

Dr. David Juurlink, head of the Division of Clinical Pharmacology and Toxicology at Sunnybrook Health Sciences Centre, and senior scientist at the Institute for Clinical Evaluative Sciences (ICES) led a bibliometric analysis of this correspondence, identifying all citations from its publication until March 30, 2017.

“We identified all 608 eligible citations of the 1980 publication, noting a marked increase in citations after the introduction of OxyContin in the mid-1990s,” says Dr. Juurlink. “It’s highly unusual for a full research study to be cited more than 600 times. For a letter to the editor, it’s almost unthinkable,” he added, noting that similar research letters published in the same journal during the same period were cited an average of 11 times.

Nearly three-quarters of articles citing the 1980 publication affirmed its original claim—that addiction was a rare consequence of opioid therapy—while more than 80 per cent overlooked the fact that the study focused only on hospitalized patients. In many instances, it was clear that citing authors hadn’t read the original publication.

Dr. Juurlink says this citation pattern played a major role in the development of the North American opioid crisis. “Fear of leaving patients addicted was a major reason why doctors tended to avoid prescribing opioids long-term. Overcoming that fear was a critical strategy for those who thought opioids were underused for chronic pain, including opioid manufacturers.” He added, “It now appears that hundreds of publications helped them do just that, by repeatedly citing a study that doesn’t tell us anything about that risk.”

Recent estimates suggest that addiction affects up to 10 per cent of patients. “We don’t have good estimates of the risk of addiction during long-term opioid therapy, but it’s certainly not rare. My sense is it’s on the order of 5 per cent, which is a staggering number considering the millions of North Americans who take prescribed opioids each day,” says Dr. Juurlink.

He adds his study highlights the potential consequences of inaccurate citation. Importantly, he says it also underscores the need for patients and prescribers to be aware of the potential benefits and harms of opioid use.

This latest research — Citation analysis of a seminal publication on the risk of iatrogenic opioid addiction — is published in The New England Journal of Medicine.

About Sunnybrook Health Sciences Centre Sunnybrook Health Sciences Centre is inventing the future of healthcare for the one million patients the hospital cares for each year through the dedication of its more than 10,000 staff and volunteers. An internationally recognized leader in research and education and a full affiliation with the University of Toronto distinguishes Sunnybrook as one of Canada’s premier academic health sciences centres. Sunnybrook specializes in caring for Canada’s war veterans, high-risk pregnancies, critically-ill newborns, adults and the elderly, and treating and preventing cancer, cardiovascular disease, neurological and psychiatric disorders, orthopaedic and arthritic conditions and traumatic injuries. For more information about how Sunnybrook is inventing the future of healthcare please visit us online at www.sunnybrook.ca

The Institute for Clinical Evaluative Sciences (ICES) is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy. For the latest ICES news, follow us on Twitter: @ICESOntario

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