NEJM issues unusual warning for readers about 1980 letter on opioid addiction

This week, the New England Journal of Medicine issued a type of editor’s note we’ve never seen before, on a highly influential letter published nearly 40 years ago.

Above the one-paragraph letter, which reports data suggesting pain medications are not likely to cause addiction, the journal has added a note warning readers that the letter has been “heavily and uncritically cited” by sources using it to suggest opioids are not addictive.

In essence, the journal isn’t commenting on the merits of the letter — the problem is how it’s been used by others.

The same issue of the journal includes a letter by researchers based in Canada who analyzed how the 1980 letter had been cited, noting:

In conclusion, we found that a five-sentence letter published in the Journal in 1980 was heavily and uncritically cited as evidence that addiction was rare with long-term opioid therapy. 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…Our findings highlight the potential consequences of inaccurate citation and underscore the need for diligence when citing previously published studies.

Here is the entire text of the letter, “Addiction rare in patients treated with narcotics:”

Recently, we examined our current files to determine the incidence of narcotic addiction in 39,946 hospitalized medical patients who were monitored consecutively. Although there were 11,882 patients who received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients who had no history of addiction. The addiction was considered major in only one instance. The drugs implicated were meperidine in two patients, Percodan in one, and hydromorphone in one. 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.

It is now preceded by this editor’s note:

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.

A NEJM spokesperson told us that the journal chose to add this type of note — the first of its kind during the tenure of current editor Jeffrey Drazen — “because the letter was being misquoted.” She added the journal didn’t consider retracting the letter, because:

According to [The International Committee of Medical Journal Editors] guidelines, articles are retracted because of scientific misconduct or serious error. This letter has neither.

In the accompanying letter to the editor, David N. Juurlink at Sunnybrook Research Institute and his colleagues report:

We identified 608 citations of the index publication and noted a sizable increase after the introduction of OxyContin (a long-acting formulation of oxycodone) in 1995. Of the articles that included a reference to the 1980 letter, the authors of 439 (72.2%) cited it as evidence that addiction was rare in patients treated with opioids.

The authors of the 1980 letter are Jane Porter and Hershel Jick; we were unable to find contact information for Porter. Jick is now an emeritus director at Boston University.

Ferric Fang, editor of Infection and Immunity — and a member of the board of directors of our parent non-profit organization — told us he took issue with some of the media coverage about the letter (such as from Forbes, the Los Angeles Times, and the Daily Beast), some of which suggests it may have triggered the opioid crisis:

As a practicing physician, I can tell you that there is a lot of blame to go around.  Nevertheless, the letter has been extensively cited and to a degree that seems unwarranted for a thirty-seven year old retrospective single center study with an undefined follow-up period.

Regarding the journal’s actions, Fang told us:

I have not seen an editor’s note like this before, but I find it to be a reasonable response to the attention that this particular letter has received.  I think this is an exceptional case, and conventional tools to handle problematic literature (e.g., retractions, errata) would not be appropriate.

He added:

I would be willing to insert an Editor’s note for an article in one of my journals if I felt it to be important to place a previously published article into appropriate context.

Fiona Godlee, editor in chief of The BMJ, told us she understood what the NEJM was “aiming to achieve” with its editor’s note — namely, to alert readers of the 1980 letter to the more recent analysis:

The long time gap between the original 1980 letter and the 2017 article about the letter has created a problem for the NEJM.

Annette Flanagin, executive managing editor of JAMA and the JAMA network, concurred with the journal’s decision:

We agree that NEJM is providing a public service with this Editor’s Note given the public health crisis associated with opioid addiction. Used cautiously and in rare circumstances, this seems like an appropriate form of post-publication communication.

In one of their STAT columns, our co-founders have noted that calls to retract papers that aren’t themselves problematic — but have been used in potentially problematic ways — are rarely a good idea.

Update 6/2/17 12:17 p.m. eastern: We heard from Steven Shafer at Stanford University, former editor of Anesthesia & Analgesia (and a member of the board of directors of our parent non-profit organization), who shared some criticisms of the editor’s note:

Yes, they did the right thing in calling attention to the indefensible decision to publish this letter in 1980. However, I don’t think their single sentence goes nearly far enough, although the Leung paper thoroughly debunks the letter. Personally, I think that the issue should have included a profound letter of apology from Dr. Jink, as well as a direct apology from the Editors of the New England Journal of Medicine. Both should be deeply ashamed to have published such data without providing adequate scientific documentation of the methodology, results, and study limitations. Both should apologize for the incredible damage, including destroyed lives, communities, and thousands of deaths traced to this irresponsible Letter to the Editor.

To be clear, I do not believe the letter is fraudulent. Indeed, I have every reason to believe that the statements in the letter are true and correct. However, the letter from Dr. Jink is so far below acceptable reporting standards as to nearly represent misconduct by both Dr. Jink and the editors of the New England Journal of Medicine.

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12 thoughts on “NEJM issues unusual warning for readers about 1980 letter on opioid addiction”

  1. Maybe a couple of questions could put the NEJM editor’s “note” in perspective. How many replications of the original cited study were performed and reported by the NEJM (or any other medical journal) between 1980 and 2017? If none at all or not enough to represent the unfolding of the opioid epidemic over the years, why? Did the NEJM and medical journals conclude a single study widely cited created “settled science.” Were there financial incentives or pressures against replication?

    That said, better late than never is the coming of the NEJM editor’s warning note.

  2. This is an odd decision. Is it really the job of editors to comment on citation patterns?

    Are we to assume that any NEJM paper which does *not* have a similar editorial note is only ever cited appropriately?

      1. So next time there is a crisis or a perceived crisis, the NEJM will have to weigh in regarding whether they’re being properly cited? I think it sets a strange precedent. Editors normally leave debates about interpretation for scientists to debate via normal channels.

        1. Yes. If the literature they approve publishing is erroneously used or cited to promote the use of any substance involed in putting the health or the life of human beings at risk, they should weigh by issuing a warning or a clarification. IMHO.

  3. Please compare this citation pattern with the one on giving pain killers to women in birth around 1900! (have no access to university library any more, therefore no citation list)
    Most authors were a little bit more honest by giving bible quotes about their god desiring women to have pain at birthas reason they were against it, back then.
    All the patient paper that is being used to deny painkillers to us who need them is nothing more than propaganda against selfdetermination, knowing well that people with chronic pain or even those with acute pain toward the end of their lifes DO MAKE their decisions in a perfectly informed way. A great majority of people prefer a shorter life without pain to prolonged suffering, even if faithheads tell us we have to fear a presumed hell in a presumed afterlife to the real hell of being denied medicine. We are NO ADDICTS, we are in pain.

    1. You are absolutely right. Everybody is entitled to a pain-free life. However, there is a difference between respecting individuals autonomy to choose whether they need to take pain killers or not, and misrepresenting addictive potential of a pain killer, the latter could lead to serious complications. Respect for autonomy includes equipping patients with knowledge about the benefits, risks and potential complications of available treatments such that they can make their own informed decisions.

  4. This short letter of 101 words seems to have affected the way physicians have medicated their patients. As Managing Editor, I would have requested financial disclosures from the authors. Moreover, the letter itself is more self-serving than serving the public and serving the interests of public debate. One of the authors, Dr. Jick, appears to have used the letter to the editor in NEJM to promote his own research in JAMA 10 years before (1970). I agree with NEJM’s decision to include an editors’ note. I would also caution authors on citing letters as appropriate evidence in their research.

  5. The opioid epidemic is worse in areas of the US where there is more economic anxiety and joblessness. This seems to contradict the theory that doctors are over-prescribing painkillers and getting their patients addicted because of an inappropriately cited letter from 1980.

  6. The problem wasn’t merely the publishing of this letter, the problem is confirmation bias. If this letter wasn’t published, it would have been something else cited to justify claims.

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