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OPIOID CRISIS
even into relatively modern times as seen during the Opium Wars in
China and with the rates of morphine addiction after the Civil War
and World War I. Because of this well-known risk of addiction,
physicians trained well into the 1970s and 1980s were taught to avoid
these medications for chronic non-cancer pain if possible and to use
the lowest doses needed when required.
This training changed in the 1990s. In 1995, Dr. James Campbell
presented, in his presidential address to the American Pain Society
(APS), the idea that pain should be evaluated as a vital sign. This dra- needed to cause an opioid reformation; this gave them “medical ev-
matically changed the way health care providers, and patients,
thought about pain. Pain became the fifth vital sign — being elevated
from a noteworthy concern, to the ranks of objective signs, such as
heart rate, blood pressure, respiratory rate, and temperature. One
can see the problem — pain, defined through the International As-
sociation for the Study of Pain as “an unpleasant sensory and emo-
tional experience associated with actual or potential tissue damage,
or described in terms of such damage,” (10) a purely subjective ex-
perience, became a focus for providers everywhere.
Maybe this alone would not have convinced providers to dras-
tically change their prescribing habits — to prescribe medications
they were historically taught were addictive and should not be used
for chronic non-cancer pain. But combined with the release of
OxyContin in 1996, and a national marketing campaign to “in-
form” physicians about its “non-addictive” potential, things
quickly changed.
OxyContin, a long-lasting formulation of oxycodone which is an
opioid approximately 1.5 times as potent as oral morphine, was re-
leased by Purdue Pharma into the United States in 1996. That year,
the new drug had earned $48 million in sales, and by the year 2000,
that number was $1.1 billion (11). This increase was accounted for
by the liberalization of opioid prescribing habits by physicians who
were being told that this was an ideal drug for non-cancer pain with
non-addictive potential (12). The pharmaceutical company claimed
this was supported by scientific literature, and often quoted the
“Porter and Jicks” article, among others, in industry-sponsored
physician education seminars.
Back up to 1980 — a single paragraph “Letter to the Editor” was
published in the New England Journal of Medicine (NEJM) by Dr.
Hershel Jick and Jane Porter which laid the groundwork for the fu-
ture dramatic change in opioid prescribing over 15 years later. The
letter in its entirety is below:
“Recently, we examined our current files to determine the inci-
dence of narcotic addiction in 39,946 hospitalized medical patients
who were monitored consecutively. Although there were 11,882 pa-
tients 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 pa-
tients, Percodan in one, and hydromorphone in one. We conclude
that despite widespread use of narcotic drugs in hospitals, the de-
velopment of addiction is rare in medical patients with no history
of addiction.” (13)
The indiscriminate conclusion was that the development of ad-
diction was rare in patients without a history of addiction. This five-
sentence letter, given without any further information beyond its two
references, gave pharmaceutical companies the ammunition they
idence” that addiction was extraordinarily rare in most patients. Nu-
merous papers began to reference the article, infamously known now
as simply, “Porter and Jick”, without noting that the article referred
only to hospitalized patients who received medications from a
trained provider — not at all analogous to self-administration on an
outpatient basis (14). As noted in the letter, these patients vaguely
received “at least one narcotic preparation,” with no mention of total
dose, dosing intervals, pain being treated, or duration of treatment.
The generalization of this letter to a chronic pain population at home
taking opioids for low back pain represented a complete misrepre-
sentation of the information provided, and those conclusions were
far beyond what the original authors intended to communicate to
the medical community.
An article in the New England Journal of Medicine (NEJM) pub-
lished this year identified 608 citations of “Porter and Jick” in med-
ical journals since its publication (14). About 72 percent of these
authors cited it as “evidence that addiction was rare in patients
treated with opioids,” and over 80 percent did not mention that the
document referred to hospitalized patients. Not surprisingly, a large
spike in the rate of citation was noted after the introduction of Oxy-
Contin in 1996.
In 2007, the manufacturer of OxyContin and three company ex-
ecutives pled guilty to criminal charges that they misled prescribers
and patients by claiming that it was less addictive, and therefore less
subject to abuse and diversion, than other opioids (15). By this time,
however, much of the damage had been done. Drug users had long
since learned to crush the controlled-release tablet to allow instant
access to its highly concentrated opioid dose, as much as 160mg of
oxycodone in a single tablet, to abuse in their intake method of
choice, be it ingesting, snorting, or injecting the drug.
An abuse-deterrent formulation of OxyContin was introduced in
2010 with the intent to make it more difficult to solubilize, but
“abuse-deterrent” does not necessarily mean “abuse-proof.” A study
in 2012 in the Journal of the American Medical Association (JAMA)
looked at the effect of the abuse-deterrent form of OxyContin in
patients with opioid dependence who were entering treatment pro-
grams in the United States (16). While the abuse of OxyContin as
the primary drug decreased from approximately 35 percent of re-
sponders to 12.8 percent within almost two years of the new for-
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