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The 1980 NEJM Letter That Fueled the Opioid Crisis - The Atlantic

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The 1980 NEJM Letter That Fueled the Opioid Crisis - The Atlantic

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Because it was published in the most prestigious U.S. medical journal, its influence snowballed in a dangerous way.

NEJM / Katie Martin / The Atlantic

But as it began to accrue citations, its findings also began to mutate. Porter and Jick had only looked at hospitalized patients in regimented settings, but that detail got lost in the push to prescribe opioids to patients at home-an entirely different scenario.

Purdue Pharma, which makes OxyContin, starting using the letter's data to say that less than one percent of patients treated with opioids became addicted. Pain specialists routinely cited it in their lectures. Porter and Jick's letter is not the only study whose findings on opioid addiction became taken out of context, but it was one of the most prominent. Jick recently told the AP, "I'm essentially mortified that that letter to the editor was used as an excuse to do what these drug companies did."

If you don't track down the original letter, it's not obvious how brief and narrow its findings truly are. (Until NEJM put its full archives online in 2010, the only way to track it down was to find a physical copy in an academic library.) And it seems like many people didn't. As Quinones writes in his book, the brief letter became a lot grander in retellings:

One researcher, writing in 1990 in Scientific American, called Porter and Jick an "extensive study." A paper for the Institute for Clinical Systems Improvement called Porter and Jick "a landmark report." Then the final anointing: Time magazine in 2001 story titled "Less Pain, More Gain," called Porter and Jick a "landmark study" showing that the "exaggerated fear that patients would become addicted" to opiates was "basically unwarranted."

There is a perhaps understandable source of confusion. Scientific journals pride themselves on peer review-where outside experts evaluate research-but the Correspondence section that published Porter and Jick's letter doesn't usually follow the same standard. It makes some sense. The Correspondence section usually consists of short letters to the editor or somewhat informal observations from doctors and scientists. Porter and Jick's letter appeared alongside others like, "Bacteriuria in Schoolgirls" and "Problems with Peppermint-Flavored Lidocaine." (Another piece of old Correspondence in NEJM infamously launched an unfounded panic over MSG in Chinese restaurants.)

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A spokesperson for the journal says that the Correspondence section today is subject to peer review on a case-by-case basis, but it is unlikely that the original Porter and Jick letter was peer reviewed. That's not to say that Porter and Jick's finding would not have passed muster, or that it is not useful in hospital settings. But the NEJM has built up considerable prestige by publishing truly landmark peer-reviewed studies, and that halo of prestige gave even this brief letter outsized importance. Published in NEJM? Sounds legitimate-especially if you don't read the actual letter.

Citations of the letter have fallen in recent years, as doctors have seen firsthand just how addictive opioids can be. On NEJM 's website, the Porter and Jick letter now has an editor's note that reads, "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." The note then links to the new study published this week. It's the only time the current editor, Jeffrey Drazen, has appended such a note in his 17-year tenure.

The outsized influence of the Porter and Jick letter is no secret, but this study sets it in the formal scientific record-in the same journal where it all started.

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The One-Paragraph Letter From 1980 That Fueled the Opioid Crisis

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Because it was published in the most prestigious U.S. medical journal, its influence snowballed in a dangerous way. But as it began to accrue citations, its findings also began to mutate. Porter and Jick had only looked at hospitalized patients in regimented settings, but that detail got lost in the push to prescribe opioids to patients at home-an entirely different scenario.

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New Bronx court allows opioid addicts to dodge jail - NY Daily News

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New Bronx court allows opioid addicts to dodge jail - NY Daily News

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Opioid addicts in the Bronx now have a chance to avoid jail through a new drug court that prioritizes treatment over punishment.

Court officials and Bronx District Attorney Darcel Clark revealed Monday that the special court opened eight weeks ago and is treating 52 defendants charged with criminal possession of a controlled substance in the seventh degree.

Addicts who fulfill treatment goals in the Overdose and Avoidance Recovery program will have their drug charges dismissed and sealed.

"It's not the normal sense of crime and punishment. Our track is about compassion and recovery," Judge George Grasso said.

Opioid Addiction FAQ: Experts' guide to the hard facts

"Now we are in full crisis mode...It's not about slapping wrists. It's about saving lives."

During a proceeding before the judge, a male defendant requested further addiction treatment at Mount Sinai Hospital through Bronx Community Solutions project director Maria Almonte.

In a departure from typical court protocol, the man did not have to be present.

Grasso commended the request.

N.Y. lawmakers urged to allow safe sites for addicts to use drugs

"We will in this proceeding bend over backward to work with him. Remind him that this isn't the normal crime and punishment. This is a very unique track," Grasso said to Almonte, who was assisting in treatment.

"I very much look forward to seeing him on Feb. 8 to get the latest information on his progress."

Clark said Daily News coverage of the crisis, dubbed "Opioid Nation," inspired her to pursue the alternative form of justice.

"The Daily News really hit it on the head with that story. That just solidified that we really needed to think outside the box and to think of something really creative to help these long term users who are at high risk of overdose," Clark said.

Brooklyn man blames Big Pharma for opioid-fueled robbery spree

The statistics are dire.

Between January 2013 and July 2017, 879 people died of opioid use in the Bronx. Of those, 551 people had an average 8.9 arrests each. Last year, 292 people were murdered in all of New York City. In comparison, the city recorded over 300 overdose deaths in the Bronx alone in 2017, Grasso said.
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New Bronx court allows opioid addicts to dodge jail

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Opioid addicts in the Bronx now have a chance to avoid jail through a new drug court that prioritizes treatment over punishment. Court officials and Bronx District Attorney Darcel Clark revealed Monday that the special court opened eight weeks ago and is treating 52 defendants charged with criminal possession of a controlled substance in the seventh degree.

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The Bronx’s Quiet, Brutal War With Opioids - The New York Times

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The Bronx’s Quiet, Brutal War With Opioids - The New York Times

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The bodies turn up in public restrooms, in parks and under bridges, skin tone ashen or shades of blue. The deceased can go undiscovered, sometimes for hours, or days if they were alone when they injected heroin and overdosed.

Terrell Jones, a longtime resident of the Bronx, was pointing to the locations where overdoses occurred as he drove through the East Tremont neighborhood, the car passing small convenience stores, rowhouses and schools.

"This is sometimes where people are being found, in their houses, dead," said Mr. Jones, 61, looking toward a housing project along 180th Street. "Especially in the South Bronx, you have so many people in housing who overdose. To actually sit there and witness this whole thing? You're watching this person turn all different colors. You know what I'm saying?"

The dramatic rise in opioid-related deaths has devastated communities around the United States in recent years, and has stirred concern among law enforcement and public health officials alike in New York City.

Here, the reports about the epidemic and its ravages have mostly centered on Staten Island, where the rate of deaths per person is the highest of the five boroughs. But perhaps nowhere in the city has the trajectory of opioid addiction been as complex as in the Bronx, where overdose deaths were declining until a new surge began at the turn of the decade, and where more residents are lost to overdoses than anywhere else in the city. On Bronx streets, the epidemic's devastation is next door, down the street, all around.

The increase in deaths - now at the highest levels since the city began collecting the data in 2000 - has been fueled by social forces that have left some Bronx residents especially vulnerable: a history of high drug use in the area; a growing supply of cheap heroin on the streets; and the proliferation of a deadly synthetic opioid, fentanyl.

Mr. Jones said he never leaves his apartment in Hunts Point without a dose of naloxone, a medication that can be used to reverse opioid overdoses. The antidote - whose brand name is Narcan - has become a necessary stopgap to prevent deaths that happen in public spaces. Mr. Jones, who has himself struggled with drug addiction in the past, now works with New York Harm Reduction Educators to help drug users.

"Regardless of how they died, it wasn't an intentional death. Nobody woke up and said, 'Today I want to die of an overdose,'" he said. "People have issues and reasons they're using drugs, and it's not for us to judge."

In 2016, 1,374 people died from overdoses in New York City, up from 937 in 2015, according to the New York City Office of Chief Medical Examiner. The vast majority of those lethal overdoses involved opioids, a drug classification comprising prescription painkillers like Oxycodone and Percocet, morphine, and the illegal street counterpart, heroin. An additional 344 overdose deaths were reported across the city from January to March of this year, according to preliminary data made available by the New York City Health Department.

More Bronx residents died of drug overdoses in 2016 than any other New York City borough - 308. That's more than double the number in 2010, 128. Fatal overdoses in the borough are now at their highest rates since at least 2000, as far back as official data is available. Eighty-five percent of those deaths involved opioids, and about 76 percent involved heroin or fentanyl specifically.

Of the five neighborhoods with the highest opioid-related overdose rates in 2015 and 2016, four were in the Bronx - Hunts Point-Mott Haven, Crotona-Tremont, High Bridge-Morrisania and Fordham-Bronx Park - and one was in Staten Island, South Beach/Tottenville.

The crisis in the Bronx stems, at least in part, from a surge of opioids in a place where some residents have long struggled with addiction. Heroin has become much cheaper in recent years as the supply in the United States has grown, according to the Office of the Special Narcotics Prosecutor for the City of New York, and individuals with histories of drug abuse are particularly vulnerable to relapse amid a surge of cheap drugs. It has also become significantly more potent.

The cheaper, stronger heroin has been made even more dangerous by the proliferation of fentanyl, which is 50 times more powerful than heroin. Interviews with nearly 200 drug users conducted by the city health department suggest that most users are not directly seeking fentanyl; narcotics experts say the drug is likely being mixed into heroin batches, often without the dealers themselves knowing, let alone users. As effective as naloxone can be in reversing overdoses and restoring breathing, fentanyl overdoses are often too extreme for the antidote to work. And naloxone is ultimately a Band-Aid to a broader, systemic addiction crisis across the city.

"In a place like the Bronx, where there was a long term underlying addiction issue, all of a sudden you saturate the area with cheap accessible heroin, and you're going to start to see the spike," the city's special narcotics prosecutor, Bridget Brennan, said in an interview.

The recent surge of illegal heroin in the Bronx in many ways mirrors the surge of prescription painkillers that fueled the opioid epidemic in suburban and rural communities. In the Bronx, as elsewhere, accessibility is related to spikes in consumption and addiction.

An illegal prescription painkiller market also thrived in the Bronx. In one high-profile case, a physician who owned several medical clinics in the Bronx was convicted of illegally distributing millions of prescription painkillers between 2011 and 2014. (Oxycodone from that "pill mill" was likely distributed in the Bronx, northern parts of Manhattan and Brooklyn, officials have said.)

In Staten Island, the proliferation of prescription painkillers - often acquired illicitly through friends or dealers - led to an explosion in overdose deaths earlier this decade. Eventually Staten Island itself developed a market for heroin dealers.

"This group of people in Staten Island, who might have been put off by the illegality of heroin, they're already addicted" to opioids, Ms. Brennan said, and were therefore more willing to try it. The ensuing rise in opioid-related deaths among white, middle-class men and women has helped change popular conceptions about who is susceptible to drug addiction.

"The impact plays out differently in different parts of the city, and different parts of the country, depending on the historical arch. But it's got a huge impact wherever it hits. It's so cheap, so accessible, so pure," explained Ms. Brennan.

Given the significantly larger overall numbers of deaths in the Bronx, Dr. Chinazo Cunningham, a primary care physician affiliated with Montefiore Medical Center who has worked in the Bronx for decades, lamented that opioid-related deaths in the borough have not received more attention. She said the interest in Staten Island likely stems from its relatively new addiction crisis and the fact that white middle-class residents are being affected.

"Really, the reason we care about the opioid epidemic is because it's affecting populations that are white and affluent," she said. "The way that we got to this is bittersweet, that this is what it has taken to shift the conversation to this way we're talking about it."

Dr. Cunningham, who is certified in addiction medicine, said it is important to balance medical data against stereotypes "portraying everyone in the Bronx as a drug user, or suggesting that all brown people are drug users." Such assumptions are partially to blame for apathy in the overdose death crisis in the borough, she said.

In fact, in 2016, the highest rate of overdose deaths in the Bronx was among white residents, followed by Hispanics, and then African-Americans. Just 9 percent of Bronx residents are classified as non-Hispanic white.

City Hall has acknowledged the high death count in the Bronx, and has pledged a broad, citywide program to drive down fatalities. In March, Mayor Bill de Blasio chose Lincoln Hospital in the South Bronx to announce the new effort. Calling the 2016 fatalities "shocking" and "a wake up call," Mr. de Blasio committed $38 million a year to an initiative aimed at reducing fatal drug overdoses by 35 percent over five years; he vowed to dramatically expand government-funded naloxone distribution throughout the city, while expanding treatment options and reducing the supply of opioids.

But community organizations on the ground and law enforcement are still struggling to curb the number of fentanyl- and heroin-related deaths.

On a Wednesday afternoon in September, a plain gray van was parked across the street from Tremont Park, on the corner of Arthur and Tremont Avenues, and a blue tarp was erected next to it. The arrangement was a perhaps modest, but nonetheless crucial, outpost in the fight against opioid-related overdose deaths in the Bronx. Throughout the year, from this makeshift bureau and several others in the borough, Mr. Jones and his colleagues at New York Harm Reduction Educators hand out information about opioid deaths, offer free naloxone, and operate a syringe exchange program. (The program is funded largely through government grants.)

Adriana Pericchi sat in the blue tent, training passers-by how to administer naloxone to someone suffering an overdose. Slipping back and forth between conversational Spanish and English with a man seeking naloxone and fentanyl test strips, she moved methodically step-by-step, beginning with an overview of the physical symptoms of overdose: blue nails or lips, skin discoloration and shallow breaths. She jammed naloxone into a test dummy's nose before playacting chest compressions and rescue breathing.

"First the breathing stops, then the brain, then the heart," Ms. Pericchi reminded the man, a heroin user, who nodded along.

Later, sitting in a nearby McDonald's, Ms. Pericchi opened up about the emotional toll felt by her colleagues at Washington Heights Corner Project and other organizations in the field.

"A lot of us are doing our best, but it's just not enough, it's not enough," she said. "You're mourning for one particular person who you knew and loved. And really quickly that avalanches into mourning for the state of the city, the state, the country."

Mr. Jones said the Bronx needs more resources to combat heroin deaths, and blamed racial politics for insufficient resources. He said policies from the War on Drugs have also made community members distrustful of the police. Speaking softly and slowly, he disclosed that he sold drugs during the 1980s to support his crack habit, eventually serving more than two years in prison.

Now, decades later, as he devotes himself to helping drug users who need help, Mr. Jones sees a continued double standard for Bronx residents, who are stripped of compassion and dignity amid an epidemic that has engendered sympathy and panic in other communities.

From his vantage point, the attitude toward the opioid deaths today is still influenced by racialized attitudes about the crack and heroin epidemics before.

"It's just color. It's like we're part of a third-world country because we're not part of the so-called privileged people," Mr. Jones said. "I could be wrong, but I'm saying that it's because of our color. It's a big issue."

BIG CITY

In the Bronx, Heroin Woes Never Went Away

On Staten Island, Rising Tide of Heroin Takes Hold

Heroin Takes Over a House, and Mom, on New York's Staten Island

BIG CITY

In the Bronx, Heroin Woes Never Went Away

On Staten Island, Rising Tide of Heroin Takes Hold

Heroin Takes Over a House, and Mom, on New York's Staten Island

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The Bronx's Quiet, Brutal War With Opioids

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The bodies turn up in public restrooms, in parks and under bridges, skin tone ashen or shades of blue. The deceased can go undiscovered, sometimes for hours, or days if they were alone when they injected heroin and overdosed.

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Why New Hampshire Has One of the Highest Rates of Opioid-Related Deaths | Best States | US News

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Why New Hampshire Has One of the Highest Rates of Opioid-Related Deaths | Best States | US News

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Series: New Hampshire's Opioid Crisis | New Hampshire Public Radio

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Series: New Hampshire's Opioid Crisis | New Hampshire Public Radio

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New Hampshire's congressional delegation is cheering a significant increase in federal funds for fighting the opioid epidemic included in the federal spending deal released Wednesday. The draft bill contains an additional $3 billion over 2017 funding levels to fight opioid and mental health crises nationally.