In 1986, Russell Portenoy and Kathy Foley published a study of 38 cancer patients who used opiate painkillers. Only two grew addicted, and they had previous histories of drug abuse. The rest remained addiction-free. To support this study, Foley and Portenoy cited, in a footnote, a 1980 letter to the editor of NEJM by one Dr. Hershel Jick titled “Addiction Rare in Patients Treated with Narcotics.” Portenoy and Foley never meant their study to be taken as an endorsement of prescribing opioids for any pain to any patient. They believed – and this is currently considered not controversial – that some brains are more addiction-prone than others. While some people can smoke 1-2 cigarettes a week for years and never get addicted, others get hooked and have to suck down two packs a day or they have no peace. Only after spending a serious amount of time with a patient, argued Portenoy, can a doctor know if there’s a likelihood of addiction. When you are working over a period of time with a cancer patient, this is feasible. But without asking these questions and studying the whole history of the patient, you can’t decide that opioids will not be addictive.
Of course, the pharma companies that wanted to make money disregarded these nuances and decided to use Portenoy’s, Foley’s and even Jick’s statements – without their knowledge or endorsement – to make an argument that opioid painkillers were not addictive, period. Of course, it was a complete misreading of what Jick actually said in his letter. One single number was extracted, ripped out of all context, and used carelessly and irresponsibly. Plus, it wasn’t even an actual study. It was just a letter to an editor cited in a footnote! But it became the central part of every Purdue Pharma pitch for prescribing more opioids. Most people who cited it thought it was a study, an actual scientific paper. In scientific papers, actual scientists referred to it as “an extensive study” and “a landmark report.” But it was not. It was in the “somebody said something to somebody in some context” kind of thing. Jick himself is adamant that he never said or intended to say that opioids are not addictive when prescribed as outpatient medication for chronic pain. He’s not happy at all about being misrepresented and used for nefarious purposes like he was.
If you are not shocked at this point, then you must be very jaded. And yes, we’ve seen all the same tactics in the COVID era.
At first, Portenoy and Foley thought they were doing important work, standing up for patients’ rights. But then gradually a consensus started to form (egged on by regulatory institutions, politicians and their pharma donors) that pain was being severely undertreated, unnoticed and unaddressed in America. Curiously, this wasn’t happening anywhere else on the planet, even though prohibitions on prescribing opioids casually and for daily little infirmities exist everywhere. This was, by the way, the time when this utterly ludicrous practice was instituted in the US healthcare of asking patients to rate their pain at a scale of 1 to 10. It’s moronic because, of course, a self-involved drama queen will screech “eleven!” whenever she has a minor scratch while a more stoic individual will say 2, even when there is real pain. What people SAY they feel means exactly that, it’s what they say. As a gauge of reality, feeling is not a great indicator. “I feel that I’m a man” is not a description of existing reality, no matter how much I might want it to be.
Between 1998 and 2005, over 900 pain clinics that studied non-medicalized treatment of pain went out of existence. Their patients were now on opioids. Insurance companies reimbursed for pills because “pain” was no considered a vital sign (no matter how subjective it is). They were not reimbursing any non-drug-based therapies. It became generally accepted in the medical profession that if a patient kept coming back for larger doses of painkillers, he wasn’t addicted. He was simply not getting prescribed enough.
OxyContin came out in 1996. The FDA allowed Purdue Pharma to claim that Oxy was less addictive because its timed-release formula supposedly allowed for a delay in absorbing the drug. This “time-release formula” became the centerpiece of the company’s aggressive marketing strategy. There’s a time-release mechanism, so you don’t get a rapid high, so it’s not as addictive. Should I list the problems with this claim or are they easy to figure out?
Purdue aggressively targeted doctors to convince, bribe and bully them to prescribe Oxy for moderate and minor pain. It also put a cute warning sticker on the packaging of Oxy, telling patients that crushing the pills will make them more potent. Not to give anybody any ideas that might get them hooked, eh? Just a fair warning from the goodness of their hearts.
Purdue sales manager for West Virginia, William Gergely, described in South Florida Sun Sentinel the sales pitch as follows: “They told us to say things like it is ‘virtually’ non-addicting. That’s what we were instructed to do. It’s not right, but that’s what they told us to say . . . You’d tell the doctor there is a study, but you wouldn’t show it to him.”
The “study” was, of course, the same old footnote based on a letter that said something completely different.
OK, this is already the size of a master’s thesis. I can go on if people want, but do they? There are other places where this story was told a lot better than I’m telling it.