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The Four-Sentence Letter Behind the Rise of Oxycontin

In 1980, the New England Journal of Medicine published a four-sentence letter written by Jane Porter and Hershel Jick, M.D., describing addiction-related outcomes for the Boston University Medical Center’s patients who had been prescribed opioids. The letter states that out of the 11,000+ patients who received opioid medications, only two of them ever developed a dependence on the drug, and only one of these was a ‘major dependence’.

Although it was published in what many consider to be the world’s most prestigious Medicine Journal, Dr. Jick didn’t think much of it at the time. A conversation with Jick about the letter is detailed in the novel Dreamland: The True Tale of America’s Opiate Epidemic (Dreamland) by Sam Quinones. In it, Jick tells Quinones that the letter’s study is at the bottom of a long list of studies he has performed since then, and that the letter didn’t attract any attention for the rest of the 1980’s. It went seemingly unnoticed for so long that its author had all but forgotten about it.

That was until Purdue Pharma, the manufacturer of prescription opioids, began to cite the letter as evidence for the safety of Oxycontin.

“The rate of addiction for patients who are treated by doctors is much less than 1%”, touts an Oxycontin TV commercial. “They don’t wear out – they go on working. So these drugs, which I repeat, are our strongest pain medications, should be used much more than they [currently] are for patients in pain”.

A poster advertising Oxycontin as "the next step in pain relief" to Canadian markets.

But this commercial (like most drug commercials) was directed towards persons suffering from chronic pain, not doctors. As with hundreds of other drug commercials, Purdue hoped patients would remember the drug’s name and ask their doctor for a prescription – which is why their use of Jick’s study is flawed.

Prospective patients acting on Purdue’s commercial would be self-administering Oxycontin after they picked it up from their local drug store – but Purdue’s “less than 1%” addiction rate comes from an excerpt about a study performed in a hospital, with patients in structured, supervised care.

Despite this discrepancy, the letter’s popularity flourished. The New England Journal of Medicine’s website notes this letter has been cited nearly 400 times. Google Scholar notes it has been cited 1,243 times.

As its popularity snowballed, the lines between ‘topical’ and ‘importance’ began to blur. A 2001 TIME Magazine feature article titled Less Pain, More Gain cited it as a “landmark study”, but its own author scarcely remembers it. Quinoes couldn’t even find a full text record of the study, reporting that it had been unavailable from its journal’s archives for at least ten years.

This seems to suggest that most citations were based on the article’s four-sentence feature, with public perceptions of its importance possibly based solely upon its citations by TIME, Purdue, and other prominent names.

An Oxycontin Ad featuring Rush Limbaugh holding a bottle of Oxycontin. A featured quote reads, "I couldn't get through my day without it!"

In the midst of the current opioid crisis, researchers are devoting more time into conducting more extensive reports on this statistic – reports that show addiction rates to be far higher than Purdue’s marketing would have you believe.

One of the more credible studies, cited by the National Institute on Drug Abuse on their webpage “Opioid Overdose Crisis”, is a 2015 study titled Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Focuses specifically on opioid misuse, looking at average prevalence rates among patients in 38 studies. The article notes the range of reported problematic use was enormous, ranging from less than 1% to more than 80%.

However, the study calculated average rates of misuse to be between 21% and 29%, and rates of addiction between 8% and 12%.

An aged Ad reading: 
"Your doctor might prescribe an opioid medication.
Less than 1% of patients become addicted."

Other, more recent studies that examine additional factors indicate those rates are far higher among specific populations. A study published in the Journal of the American Osteopathic Association, for example, cites the rates of adverse effects of opiate medications to be somewhere around 30%.

The article’s lead author Kevin Bain, MPH, PharmD, co-founder and medical director at Biophilia Partners, said that while the 30% described does not specifically denote addiction rates, it could still be highly relevant to the addiction process.

“The concern we have is that patients may not get the proper amount of pain relief due to an undetected interaction with some other medications they’re taking,” said Dr. Bain in a press release. “That can lead to them taking higher doses of their prescribed opioid and more frequently, which over time can lead to a substance use disorder or even an overdose.”

Bain goes on to stress the importance of informing doctors of current medications, and recommends patients stagger their medications to help avoid problematic drug interactions. Numerous other recent studies have pointed to other factors regarding the prevalence of Opiate Use Disorders (OUDs). Possible influences vary widely, including pregnancy, ADHD, and just about everything in between.

Oxycontin is a complicated drug, with hundreds of thousands of patient testimonials warning bystanders away from its seller’s false promises. If the pharmaceutical industry had held patient reports in as high esteem as lab reports, our nation might have dodged much of the tragedy we face today.

A mourning woman at an Opioid Crisis rally holds a poster featuring a young man she lost to the crisis. 

The poster uses the social media tag "#NotOneMore".

Written by Joseph Detrano, CAS Writer
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the Center of Alcohol & Substance Use Studies.