June 1, 2017

The 5 sentences that helped spark the opioid crisis

Daily Briefing

    A widely-cited letter to the editor of the New England Journal of Medicine (NEJM) was largely misinterpreted and misrepresented by providers and drugmakers to suggest that opioid addiction was rare, helping spur today's opioid epidemic, according to a new analysis, published alongside an editor's note, in NEJM.

    Learn the 8 steps for deploying clinical pharmacists in ambulatory care

    A misinterpreted letter

    In the one-paragraph letter to the editor, Hershel Jick, a drug specialist at Boston University Medical Center, cited data showing that of about 12,000 patients prescribed pain medication at a Boston hospital, only four individuals misused the opioids. The letter stated, "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."

    According to the Associated Press, physicians at the time of the letter's publication were wary of opioids, concerned that patients would misuse the drugs. However, AP reports that many drugmakers and physicians interpreted the letter as suggesting that opioid addictions were rare among people with no history of drug misuse.

    But according to Jick, his letter referred only to patients in the hospital using opioids for a short period of time—and sheds no light on long-term outpatient use of the drugs. Nonetheless, following the letter's publication, physicians began prescribing opioids more freely and citing Jick's findings —often incorrectly—in their own research, according to the analysis.

    Letter contributed to opioid epidemic, new analysis states

    In the new analysis, David Juurlink, a physician at the University of Toronto, and colleagues found that Jick's letter had been cited 608 times, and most of them inaccurately presented the findings by failing to account for the data's limitations.

    Overall, 72.2 percent of the citations used the letter as evidence to suggest that the risk of addiction was rare, and 80.8 percent of the citations failed to specify that the patients in Jick's assessment were hospitalized when they were prescribed the drugs—a very different population, the analysis authors wrote, than those who currently get opioid prescriptions outside of the hospital to manage chronic pain conditions.

    The analysis concluded, "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."

    Moreover, Juurlink pointed out that hospital databases were limited at the time the letter was published, which means that there might have been additional cases of drug misuse that were overlooked or only discovered after the patients were discharged.

    Editor's note: 'We know that not to be true'

    The editor's 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."

    Jeffrey Drazen, the chief editor at NEJM, added, "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."

    And Juurlink added that even though many more recent citations of Jick's letter have been appropriately critical, "the damage has [already] been done." He said, "And it's not just addiction that's all over but also faulty pain management—the fact that people are being more critical of the paper doesn't really matter. We now have to help people with addiction and people with pain, and to do that, we as doctors have to change."

    Looking ahead

    In addition to the analysis and editor's note, NEJM also published a new report from NIH director Francis Collins and Nora Volkow, the head of the National Institute on Drug Abuse. In the report, Collins and Volkow promise to collaborate with industry stakeholders to develop new methods of preventing and reversing overdoses, to treat people who misuse drugs, and to find new, non-addictive methods of chronic pain management.

    According to Collins, NIH over the next six weeks will host three workshops with leaders in the drug industry to establish next steps. While the details have not been finalized, the collaboration aims to cut in half the usual time it takes to develop new treatments.

    "Industry's interest in this has been muted until recently," Collins said, but now, "they feel the responsibility and the opportunity to take part in this and they're not going to stand back and watch." He added that with the FDA's interest in accelerating the development of new pain drugs, "the stars are aligning. ... I think we can make real progress now" (Marchione, Associated Press, 6/1; Diamond, Politico Pro, 6/1 [Subscription required]; Zadrozny, Daily Beast, 6/1; Juurlink et al., NEJM, 6/1).

    Learn the 8 steps for deploying clinical pharmacists in ambulatory care

    As the number of medications rises, so does the opportunity for medication errors, such as incorrect dosages, drug interactions, and serious side effects. By some estimates, the U.S. spends as much money correcting these medications problems as we do on the drugs themselves.

    Check out our infographic to learn eight steps for how to deploy clinical pharmacists in outpatient clinics.

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