Alan Cassels is a pharmaceutical policy researcher at the University of Victoria, British Columbia, a journalist, and author of the The Cochrane Collaboration: Medicine’s Best-Kept Secret.
“Falsehood flies, and the Truth comes limping after it; so that when Men come to be undeceiv’d, it is too late; the Jest is over, and the Tale has had its Effect…” Jonathan Swift, The Examiner, 1710
A very short letter published on January 10th, 1980, in The New England Journal of Medicine may be one of the main tributaries to what is now a flood: North America’s current opioid epidemic. Titled “Addiction Rare in Patients Treated with Narcotics,” the five-sentence letter by Dr. Hershel Jick was “heavily and uncritically cited as evidence that addiction was rare with long-term opioid therapy,” according to a recent bibliographic analysis by Toronto pharmacologist Dr. David Juurlink.
As Juurlink wrote in NEJM last week, the 1980 letter was cited in other medical journal articles over 600 times, contributing to a narrative that “allayed prescribers’ concerns about the risk of addiction associated with long-term opioid therapy.”
This new finding of the letter being repeatedly–and misleadingly–cited as evidence was covered by several news outlets, including Stat News, Voice of America, Associated Press, and HealthDay, among others. But the very fact that this one small letter spun so far out of control made me wonder: Where were the journalists when this misinformation was being spread, over and over, by medical researchers?
Juurlink is with the division of clinical pharmacology and toxicology at Sunnybrook Health Sciences Centre in Toronto, knows a thing or two about opioids. The last time we discussed opioids, Juurlink laid out a few essential points for journalists to keep in mind–in particular, the commonly addictive nature of opioids and the danger of using high-dose opioids, and yet also how the crisis is resulting in the medical community finally starting to respond in positive ways to treat it.
The letter’s use of the word “rare” to describe the rate of addiction was referring to a hospital setting of 11,000+ patients where only four cases of opioid addiction were seen. The problem is that while the letter was cited over 600 times as proof of the safety of opioids, few writers and researchers citing it went back to see what it said in its proper context: That the letter’s authors were referring to patients treated in a hospital under the supervision of physicians–and given short-term therapy–for acute-care situations, like surgery.
This is a far cry from community-based settings (where the majority of opioids are prescribed) where patients with lower back pain or sprained joints may be given a long-term opioid prescription that could result in a potential addiction.
Still, the letter was frequently cited as proof that opiods weren’t addictive. It was even used in a promotional video produced by the pharmaceutical manufacturer indicating how safe the opioids were:
“Our findings highlight the potential consequences of inaccurate citation and underscore the need for diligence when citing previously published studies,” Juurlink wrote.
For some context to this rethink of the dangers of opioid addiction, I spoke to Dr. Michael Bierer, an addictions specialist from Boston who’s also a regular HealthNewsReview.org contributor. He told me that when he was in medical school in the early 1980s there was an undercurrent that physicians needed to do a better job managing patients’ pain.
“There was this sense of the undertreatment of pain and a fear of using opioids,” Bierer said. The NEJM letter “satisfied a need in people justifying the lowering of the threshold,” for treating pain. Having said that, what surprises him most is the impact of the letter and how broadly it was cited.
“People seemed to accept this reference without looking at what it said. As well, letters are not peer-reviewed and aren’t given the same scrutiny as a research article,” he noted.
Perhaps we can use this as a cautionary tale for how any of us should check any citations or claims “cited” from prestigious journals. Here are some things to consider:
What kind of citation is it? A letter published in a medical journal is as far from a double-blind randomized control trial as to be in a different galaxy–and thus they should never exert the same sort of strength of gravitational pull.
What is the context? As many as 80% of the citations didn’t note that the “rare” addiction seen in Jick’s patient set may have been largely due to the fact they were in hospitals, a different sort of patient altogether than would be seen in the community.
Does the pedigree really matter? When you cite a “study in the New England Journal of Medicine” this could be misleading on a number of levels. We humans rely on shorthand heuristics to help guide us through complicated matters. An article in the NEJM or The Lancet may give the high-level imprimatur of the subject being reliable and valid, and so we may not look any further. But even prestigious journals can be fallible, and their studies can be misquoted or inappropriately cited. (Remember vaccines and autism?) Be sure to carefully vet what you’re citing.
Even the work of independent ‘experts’ can be misconstrued. Jick and his graduate student co-author were not on the payroll of the drug companies “I’m essentially mortified that that letter to the editor was used as an excuse to do what these drug companies did,” said the author of the letter, Dr. Jick, a drug specialist at Boston University Medical Center, to the the Associated Press.
The note to file here: Even if the “experts” being cited are independent, it doesn’t mean their words can’t be twisted out of context and used to support a marketing message. As Jick said, the drug companies “used this letter to spread the word that these drugs were not very addictive.”