Opium Poppy

Swallowing the Red Pill

How misquotation of a 5-sentence letter to the editor fueled the opioid epidemic.

Drug overdose is the leading cause of injury death in the United States with nearly half of all opioid overdose deaths involving a prescription. How did we get here?

Though long and convoluted, the history of the opioid epidemic finds at its origin the mangling of a brief report appearing in the January 1980 issue of the New England Journal of Medicine.

Among the most frequently cited references regarding the (lack of) addiction potential of opioids is a five-sentence letter to the editor submitted by Jane Porter and Dr. Hershel Jick of the Boston University Medical Center.

The brief communication describes the incidence of "reasonably well documented" addiction in "hospitalized medical patients" receiving "at least one narcotic preparation" (Porter and Jick, 1980). The incidence of 4 documented cases of addiction among the 11,882 patients described in the letter has been transformed into a "manifesto for the use of prescription of opioids to treat chronic, non-cancer pain" (Cleary et al., 2016).

'Like the old-fashioned game of telephone, one research report quoted the next, and it seems that no one bothered to do the essential work of looking up the original citation to see what it said and reference it accurately.' (Cleary et al., 2016)

"Dreamland: The True Tale of America's Opiate Epidemic" by Sam Quinones describes how the serial misquotation of the letter enabled the prescription opioid abuse rampant today. But surely in 2017 peer-reviewed journals are free of such errors?

Unfortunately, no. Using a bibliographic search engine to identify recent articles citing the original letter to the editor (Porter and Jick, 1980), it was surprisingly easy to find an example:

'Porter and Jick found 4 addiction cases among 12,000 patients prescribed with opioid analgesics, indicating that the long-term use of opioids are not associated with dependency.' (Lee et al., 2016)

While consistent with previous (incorrect) characterizations of the letter to the editor, this is not accurate. Porter and Jick describe "hospitalized medical patients who were monitored consecutively"who received "at least one narcotic preparation". Their letter makes no mention of duration of use; extrapolation from the five-sentence letter to support chronic non-hospital use is not prudent.

For the past 37 years, the letter to the editor by Porter and Jick has been referenced as though it were a detailed peer-review study when it was nothing more than an anecdote offered by a clinician. The serial misquotation of scientific findings can have a domino effect: opioid prescriptions for chronic non-cancer pain are directly linked to the epidemic of opioid addiction. The proliferation of opioid prescriptions for chronic non-cancer pain was predicated on the false belief of low risk of addiction. The Porter and Jick letter is frequently cited as proof of low risk.

What is the moral of the story?

In a time when truth is imperiled and distrust rampant, taking care to be precise is a critical step in ensuring ongoing dialogue between scientific and non-scientific communities. Let us not be distracted by small preventable errors.

1) Understand your obligations for confirmation of secondary sources

How did so many reputable scientists come to grossly misrepresent a reference? Secondary sources, many of which are often not peer-reviewed (they may be book chapters, for example), are often the root cause.

As an author, you bear responsibility for verifying the accuracy of all sources cited. Where a secondary source sets forth a fact critical to your hypothesis, confirming the citation from the primary (original) source is imperative.

2) Speak up

If you read what appears to be an erroneous representation of the primary source, contact the author and use peer-review comment sites to start a dialogue.

3) Keep things in perspective

One slight misquotation does not invalidate the message being conveyed. Let us remember that we are all human and we all make mistakes. If you make an error, own it and move on; if you find an error, point it out and move on.

And always remember that subsequent authors rely on the precision of your work.

Cleary M, Sayers J, Walter G, Nicoll L. "Did I really say that?" Quoting, misquoting, and misinterpretation: Academic integrity in writing for publication. Nurse Author and Editor. 2016; 26(2):1.
Lee J, Yoon J, Lee J et al. Clinical usefulness of long-term application of fentanyl matrix in chronic non-cancer pain: Improvement of pain and physical and emotional functions. Clinics in Orthopedic Surgery. 2016; 8:465-474.
Porter J, Jick H. Addiction rare in patients treated with narcotics. NEJM. 1980; 302(2):123.
Quinones S. Dreamland: the true tale of America’s opiate epidemic. Bloomsbury Press. New York. 2015.

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