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Porter & Jick, Dreamland, and The New England Journal of Medicine

The New England Journal of Medicine startled everyone this week by a posting a one-sentence warning over the so-called Porter & Jick letter to the editor that the journal published in January of 1980.

The warning 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.”

I find it remarkable that the NEJM did this, particularly so long after the letter itself was published in the journal. Apparently this kind of note is very rare.

But I think it confirms what I wrote in Dreamland – in which I interviewed the main author of the letter, Dr. Herschel Jick.

I think it’s important to reiterate the impact, as well as the intent, of the letter.

As written, it is entirely correct. That a data base of hospital patient records, that Dr. Jick ran, and still runs, found the following: of 11,800 patients given narcotic painkillers while in hospital, only four developed an addiction to those drugs.

Remember this was data taken from the 1960s and 1970s, a time when narcotic painkillers were rigorously controlled, and never given to patients to take home with them. So it stands to reason that patients, under such strict controls and administered the drugs only in hospital, would rarely develop addictions – as the letter’s headline in the journal read when it was published: Addiction Rare in Patients Treated With Narcotics.

They simply didn’t have access to large supplies of narcotics, and especially drugs to take home with them, as patients routinely do today. Hence they didn’t run much risk of addiction. (The whole thing, btw, helped change my mind about what ignites a scourge of addiction, which I now believe is not demand, but supply. Supply first sparks demand.)

The problem came not with how the letter was written, but how it was interpreted, then used, by others. Through the late 1980s and 1990s, it was widely cited, quoted, footnoted – as my research in Dreamland made clear and as a recent letter to the NEJM from the Canadian doctors confirmed. It was deemed to be proof that somehow science now knew that addiction was rare when opiates were used to treat pain. Through the years, it became known, through a process similar to a game of telephone, as some kind of “landmark study” that presumably refuted much about what we know about narcotic painkillers and addiction.

The Porter & Jick letter – 101 words – neither did, nor intended, anything of the kind.

It was also used, of course, by pharmaceutical companies – especially Purdue Pharma, manufacturer of OxyContin – as proof that their drugs no longer caused addiction when they were used to treat pain. The company used the statistic that “less than 1 percent” of all patients administered opiate painkillers drugs – especially OxyContin – grew addicted to it. This was not true nor supported by any science. It was not supported by Porter & Jick, which was making an entirely different observation. Yet the letter was used to convince a generation of doctors that science now knew new things about narcotic painkillers and one was that they were “virtually nonaddictive” when used to treat pain. A claim that, again, has no basis in science or the letter.

All this I wrote in Dreamland, which came out two years ago. I found the whole story to be an unsettling episode in how scientific thinking changes based on no evidence at all, but due instead to deft and relentless marketing.

I’ll add one more thing. The NEJM’s warning note was prompted, as I said, by a review of the letter and its influence in scholarly studies that was published by some Canadian doctors in the journal this week.

I read the letter these doctors wrote and I don’t see Dreamland credited or footnoted.

I’m trying to take it all in with equanimity. Yet I’ll admit to some frustration to have done so much research and storytelling that brought this to light as part of Dreamland’s larger story of how this opiate-addiction epidemic spread, and which others have read and learned from, and then not have it reflected in the work those people do. On the contrary, the Canadian doctors’ letter is presented as some new revelation, which it is not.

So I’ll just say that it would have been nice to see my work credited in the recent NEJM report by those Canadian doctors, as well as media coverage of that letter. I’ll leave it at that.

 

 

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A Doctor’s View of Pain Pills

Here’s a letter from doctor with a long exposure to the problem of addiction and pain pills. I get lots of email letters about Dreamland. I’ve put a few up on this blog – always with names and identifying details removed.

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 I have recognized for many years, at least since the late 1980s, that the chronic use of opioid medications was typically a barrier to recovery. I am a physiatrist, a physician procter-1specializing in physical medicine and rehabilitation, since 1986.  We manage patients who have catastrophic injuries: spinal cord injury, traumatic brain injury, amputations and those with multiple and severe trauma. I also treated many patients who had less severe injuries including strains, sprains and other soft tissue trauma. We often manage patients over many years. When the use of opioids became more frequent, in the late 1980s, I was perplexed. I did my best to manage pain, if at all possible, without the use of chronic opioid therapy. I was perplexed even more so in the mid to late 1990s when Oxycontin came on the scene. Physicians no longer were afraid to prescribe opioids for non-cancer pain and did so seemingly without caution. They were duped. Drug companies and their physician spokesmen duped them.

I grew up and later practiced medicine for many years in New Mexico. New Mexico, as you may know, has always had one of the highest drug overdose rates in the nation.  Heroin had been the drug of choice, at least until opioid medications came on the scene. I worked as a house painter’s apprentice in the late 1960s while in college. I worked on one crew that every journeyman painter was an ex-con related to heroin use.  I had plenty of opportunity to use heroin but it scared me. My co-workers told me how great it was. One guy, much older than me, made it sound so appealing. “Come over and we will shoot up and listen to jazz.”  I never tried it though I had lots of opportunity.

I knew quite well how dangerous heroin was and never believed that opioid medications were any less dangerous. When I started practicing in the late 1980s many of the patients I saw were on opioid medications when I assumed their care. Most of the more seriously injured patients I saw were successfully weaned off opioids. Many of the less seriously injured, especially those with work related injuries, were much more difficult to wean. Some patients of both categories ended up on long term opioids but were closely monitored to determine if they were benefitting from opioids and whether they were abusing them. Escalating doses were typically not allowed.

The work related injury group of patients who generally had much less severe injuries, were routinely on opioid medications when I took over their care. My job as a rehabilitation physician was to get them back to their usual activities including return to work. I found that opioid medications were a barrier to their recovery. Some of my referring physicians believed the standard of care was to treat pain with opioids as long as patients complained of pain. Some patients were never going to stop complaining of pain and the reasons were frequently psychosocial in nature. I never believed the hype from drug companies regarding the safety of opioids. I saw from up close as a young man and as a doctor that they were dangerous and in general not appropriate for long term use in non-cancer pain.

I knew little about Dr. Russell Portenoy at the time of the opioid prescription explosion but I knew plenty about what drug companies were saying about the safety of opioid medications and the unlikelihood for addiction. I now understand Dr. Portenoy’s role in this public health catastrophe.  I don’t believe Dr. Portenoy and other drug company marketer’s claims that they are now surprised about the addiction potential and danger of opioids. Intuitively it did not make sense. Oxycodone and hydrocodone are so similar to morphine and heroin both chemically and by their mechanism of action. Why would you believe they are so much safer? Those guys were either just plain dumb and so drunk with drug company money and self promotion that they refused to pay attention to what was happening to patients. I am sure they are not dumb. Dr. Portenoy is a brilliant and charming guy. Just view his video presentations and interviews. He is also a successful academic physician. That is what made him so dangerous.  I am just an average doc who has never had a higher academic position than a clinical assistant professor.  I have never authored a paper that made it to a medical journal. How could I know more than them and have been so right about the proper role of opioid medications?  Why didn’t they? Certainly not because I am smarter.Grand Canyon Trip 2015

I think your book was very even handed, maybe a little too much, with Portenoy and the other opioid selling/promoting physicians. I’m telling you they knew better. Their response of “If I knew then what I know now….” just doesn’t cut it. They are responsible for the hundreds of thousands of deaths and ruined lives. They should not get off the hook. I suspect their narcissism will prevent even one sleepless night for the damage they have done. But they and their benefactors, the drug companies, have created a horrible health crisis that was largely preventable in the United States. It is almost strictly a U.S. problem caused by U.S. physician “thought leaders”, drug companies and misguided bureaucrats.

I applaud your book. Bringing the black tar heroin story into your narrative was great. You connected the dots. I wasn’t aware of that part of the story. Thanks again for your book. It may just impact our legislators and government officials even more so, to focus on rehabilitation not punishment for those young kids who got caught up in a drug problem often caused by misguided or crooked doctors.

The punishment of “pill mill” docs and drug company marketers including their corrupt physician lackeys could never be equal to the suffering they have created. Glad you spotlighted the problem and did it in such a well-researched, entertaining and cogent way. Thank you.

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Forcing Pharma to Pay To Take Back Drugs

The Los Angeles County Department of Public Health is today holding hearings on a proposal that would force pharmaceutical companies to pay to “take back” their drugs and needles that are not used by consumers.

Los Angeles County is following the lead of Alameda County in northern California, which enacted an ordinance requiring pharmaceutical companies to provide funds to collect and dispose of unused pills. The ordinance survived Supreme Court review last spring, and is now in place under the concept of Extended Producer Responsibility (EPR).

According to the L.A. County department’s website, “EPR is an environmental protection policy approach that recognizes the responsibility of a manufacturer or producer of a product to steward that product through the post-consumer stage of its lifecycle.”

This has become an issue due to overprescribing of addictive narcotic painkillers over the last two decades – often following routine surgeries. Frequently patients are prescribed 60 or 90 Vicodin, Percocet, or Oxycontin pain pills, of which they often use only a small fraction, leaving the rest in their medicine cabinets. Many of those pills have been discovered by kids in the home, their friends, by workers doing jobs at houses, or otherwise entered the black market.

These overprescribed and unused pills have added enormously to the street supply of pills and are a large part of why the country is in the midst of an unprecedented scourge of opiate addiction.

Profits from the sale of these pills have accrued to pharmaceutical companies, while the costs of dealing with that addiction have been borne by taxpayers – cities, counties, jails, coroners, police and public health departments.

One response has been Drug Take-Back days, which have spread nationwide. In 2014, 5 million pounds of drugs were taken back during these events nationwide, according to the National Safety Council. (LA County’s interim health director estimates some 200 million pounds remain of these drugs remain in medicine cabinets around the country.)

Of course, the problem is who pays to take back these drugs, and to then dispose of them. Up to now, again, public agencies, typically cities, counties or the DEA, have foot the bill.

The move to push pharmaceutical companies to contribute is new. Counties and cities across America might want to look into this new kind of ordinance as they cast about for ways to pay for taking back the enormous quantities of highly addictive painkillers still out there.

 

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