Avril Lavigne: In 2015 the singer-songwriter told People magazine that she had been sidelined by Lyme. “I felt like I couldn’t breathe, I couldn’t talk, and I couldn’t move. I thought I was dying.” Despite her fame and fortune, Lavigne encountered many of the same obstacles as other sufferers: the doctors didn’t believe her symptoms were related to Lyme disease. “I had doctors tell me I was crazy and they didn’t want to test me. I had to learn about Lyme completely on my own.”
Alli Hilfiger: The actor—daughter of fashion icon Tommy Hilfiger—was bitten by a tick in 1992 when she was seven years old. Her parents had the tick tested, but the results were inconclusive, so they forgot about it. After that, Hilfiger’s teenage years were mired by a mysterious illness—at first her doctors thought it was multiple sclerosis, then fibromyalgia, and then rheumatoid arthritis, but none of the treatments were working. She was in nearly constant pain, her memory was failing, and she couldn’t read. It got so bad that she was admitted to a psychiatric hospital. “I was convinced that bugs were crawling up my body,” she recalls, “eating at my organs and brain.” Finally, when Hilfiger was 19 years old, it was her psychiatrist who told her that the only thing that could explain all of her symptoms was Lyme disease. She tested for it again…and was formally diagnosed. In 2016 Hilfiger wrote a book about her struggles called Bite Me; she is still dealing with Lyme today.
…plenty to eat the previous spring and summer, resulting in healthier children.
Alec Baldwin: Baldwin’s first tick bite was around the year 2000, and then he received more bites a few years later and has been battling chronic Lyme ever since. He kept it secret until 2017, when he finally opened up about his experiences: “I got the classic Lyme disease symptoms for…five years, every August, like this black lung, flu-like symptoms, sweating to death in my bed…The first time was the worst of all…I was lying in bed saying, ‘I’m going to die of Lyme disease in my bed’ and ‘I hope someone finds me and I’m not here for too long.’ ”
Daryl Hall: Hall’s symptoms began in 2006 as uncontrollable tremors. He tested negative for Parkinson’s disease, which was a relief at first, but the symptoms kept getting worse: debilitating joint pain and stiffness. It got so bad that Hall had to cancel part of a tour. He told his ex-wife about his illness, and she told him to get tested for Lyme (she’d had the disease herself). “Lyme is many things,” Hall explains. “One day you can feel like you have arthritis in your leg, and the next day it feels fine, and the next day you have brain fog. If you have any one of those symptoms and they are moving around your body, that is a big clue that you could have Lyme disease.” In 2016 Hall announced he was mostly symptom-free, except for occasional flare-ups.
Marla Maples: The former wife of Donald Trump says she’s been battling chronic Lyme for more than three decades, summing up the one thing that everyone who’s dealt with Lyme can agree on: “It’s a tragic disease.”
BACK FROM THE DEAD
The coelacanth (pronounced “SEE-luh-canth”) is a prehistoric creature that lived in the oceans off what’s now Africa. These dinosaur-like fish grew to a six and a half feet long, and stalked undersea prey with their razor-sharp teeth as far as 2,300 feet below the surface. Like dinosaurs, they were thought to have died out 66 million years ago. But they didn’t go anywhere—for millions of years, they quietly hung around in the super-deep parts of the ocean. A coelacanth was discovered in 1938 when one was inadvertently captured by a South African trawling boat.
How did the “English sweat” plague of 1485 get its name? Victims sweated to death in 24 hours.
A LETTER TO THE EDITOR
How much of an impact can a one-paragraph letter have on the world?
JUST WONDERING
Dr. Hershel Jick was a professor of medicine at the Boston University School of Medicine in the late 1970s. One of his interests was tracking both the positive and negative side effects of pharmaceutical drugs. To that end, he’d set up a database containing records of the more than 300,000 patients who’d been treated at the school’s teaching hospital in recent years.
In the fall of 1979, Dr. Jick had a question about painkillers that he wanted answered: How many patients who’d been prescribed powerful opioid-based drugs while in the hospital became addicted to them? Opiates, also known as opioids, get their name because they are derived from, or are synthetic forms of, substances found in the opium poppy. Morphine and the street drug heroin are both opiates.
Dr. Jick asked a graduate student, Jane Porter, to search the database for the answer. She did the research and Jick summarized her findings in a 101-word letter to the editor of the New England Journal of Medicine, one of the country’s most prestigious peer-reviewed medical journals.
“Although there were 11,882 patients who received at least one [opiate] preparation,” Jick wrote, “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…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.” As was customary with such letters, Jane Porter signed it first—because she did the research—and then Dr. Jick signed it. In time it would come to be known by the nickname “Porter and Jick.”
The New England Journal of Medicine published the letter in its January 1980 issue under the headline “Addiction Rare in Patients Treated with Narcotics.”
For more than a decade, the letter was ignored.
A LITTLE DAB WILL (HAVE TO) DO YA
In those days, opiates were administered only in hospital settings, and under the close supervision of a physician. This was because opiates are terribly addictive. It was drummed into doctors, from medical school onward, that opiates were dangerous for the patient. Prescribing them was done only as a last resort, and usually only for terminal cancer patients or people recovering from surgery. That was it. Even these patients were prescribed opiates for short periods of time and at low doses, often in a form that combined them with less addictive drugs, so that less of the opiate was needed. Percodan is a combination of aspirin and the opioid oxycodone, for example, and Percocet is oxycodone combined with acetaminophen, the active ingredient in Tylenol.
In 1827 France blockaded the port of Algiers for three years, after its ruler swatted the French consul with a fly whisk.
In a hospital setting, the patient could be closely monitored for signs of addiction and overdose. If necessary, the dosage of opiates could be reduced or eliminated entirely, and milder, less-effective drugs substituted in their place. Increased pain might be the result, but that was the trade-off that had to be made to spare the patient from becoming addicted to painkillers. Patients were never prescribed opiates that they could take at home after leaving the hospital. The risk that they would abuse the drugs and become addicted, or even die from an overdose, was thought to be far too great.
ON SECOND THOUGHT
In the mid-1980s, however, attitudes in the medical community began to change. Pain researchers—some of whom were already beginning to cite Porter and Jick as evidence to support their claims—came to believe that opiates could be safely prescribed to patients who had no prior history of drug addiction. The thinking was that some people had addictive tendencies, but most people did not. By questioning a patient carefully, a physician could determine whether a patient had tendency toward addiction. If they didn’t, the physician could prescribe opiates with little risk of the patient abusing the drugs or developing an addiction.
“At the core of this culture was the idea that these painkillers were virtually nonaddictive when used to treat pain.”
Another idea that became popular was the belief that a patient’s pain blocked the euphoria effect that makes opiates so addictive in the first place. People in pain could take the drug without fear of becoming addicted, because their pain would cancel out the euphoria and prevent addiction from taking hold.
Where pain had once been seen as an unfortunate but necessary trade-off to prevent patients from becoming drug addicts, now many in the medical community were beginning to see pain as an easily treatable symptom that in too many cases was going untreated. “All of this happened in about a decade,” Sam Quinones writes in Dreamland: The True Tale of America’s Opiate Epidemic. “At the core of this culture was the idea that these painkillers were virtually nonaddictive when used to treat pain.”
TO BE CONTIN-UED
That’s what the pain specialists had come to believe, but many ordinary physicians were still reluctant to go against a lifetime of training and prescribe opiates to their patients. Then in 1995, a drug company called Purdue Pharma won FDA approval for OxyContin, a time-release form of the synthetic opiate oxycodone, which is roughly 1.5 times more powerful than morphine.
Thanks! Spiders eat as many as 800 million tons of insects each year.
Each OxyContin pill contained a massive dose of oxycodone, but because the pills were formulated to slowly release the drug into the body over twelve hours (the “contin” in OxyContin stands for “continuous release”), Purdue argued that they were a safer form of opiate, which the pain specialists already believed were fairly safe.
SALES PITCH
To win over skeptical physicians, Purdue launched a marketing campaign to convince them that OxyContin’s time-release feature made it safe not just for cancer patients and people recovering from surgery, but for people suffering from other forms of pain as well. One piece of evidence cited over and over was Porter and Jick’s letter to the New England Journal of Medicine, now 15 years old. Even though the New England Journal of Medicine is a medical journal that publishes peer-reviewed scientific papers, letters to the editor, including the one from Porter and Jick, do not receive the same rigorous, skeptical scrutiny when being considered for publication. Indeed, it’s not clear that the Porter and Jick letter received any scrutiny before it was published. It was just a letter to the editor, after all. When Purdue Pharma and others cited Porter and Jick, it usually included just the headline (“Addiction Rare in Patients Treated with Narcotics”), the fact that it had been published in the New England Journal of Medicine, and—remarkably—the claim that Porter and Jick had supposedly found that “less than 1 percent of patients” to whom opiates are prescribed become addicted to them.
The letter from Porter and Jick wasn’t a peer-reviewed scientific paper, and it did not make the claim that “less than 1 percent of patients” to whom opiates are prescribed become addicted to them. The only patients who had been studied were ones who were in a hospital, where they were carefully monitored by a physician for any sign of addiction.
Anyone who went to the trouble of looking up the letter and reading it for themselves would have discovered this right away. But doing so took some work. In 1995 the New England Journal of Medicine’s online archives went back just a few years; the only way to obtain information published as far back as January 1980 was to go to a medical library that had back issues on their shelves and retrieve the magazine by hand.
SEEING IS BELIEVING
Not many people did. When physicians read the headline “Addiction Rare in Patients Treated with Narcotics” and saw that Porter and Jick had been published in the New England Journal of Medicine, they naturally—and tragically—assumed that it was a peer-reviewed scientific paper. They accepted on faith that the claim that “less than 1 percent of patients” ever became addicted to opiates. And they assumed that there was strong scientific evidence to support it.
The name for the disease malaria—“bad air”—dates back to the days when people had no idea how it was spread. (You get it from mosquito bites.)
“That single paragraph, buried in the back pages of the New England Journal of Medicine,” Sam Quinones writes in Dreamland, “was mentioned, lectured on, and cited until it emerged transformed into, in the words of one textbook, ‘a landmark report’ that ‘did much to counteract’ fears of addiction in pain patients treated with opiates. It did nothing of the kind.”
AND AWAY WE GO
Purdue Pharma’s sneaky marketing campaign paid off: physicians became much more comfortable prescribing OxyContin and other powerful opiates to their patients than they were before. And their patients, having been persuaded by the “experts” that the drugs were safe, eagerly took them, not just to control severe pain from surgery and terminal cancer, but also for sports injuries, broken bones, arthritis, and lower-back pain. They even took them for toothaches, headaches, and sore knees. The opiates weren’t just administered in the hospital under medical supervision, either; patients were routinely sent home with bottles filled with pills more powerful than heroin, and were trusted to administer the drugs themselves, with no medical supervision at all. After all, if the pills were as safe as everyone said they were, what was the risk?
Some 76 million prescriptions for opiate-based painkillers were written in the United States in 1991, and the number climbed year after year. By 2012 it had more than tripled, to 282 million prescriptions. Purdue Pharma sold more than $3.1 billion worth of OxyContin that year; that one drug represented more than 90 percent of the company’s total sales.
CHEW ON THIS
But as drug users already knew—and many patients prescribed OxyContin soon discovered—the time-release property that made the pills so “safe” only worked if the pills were swallowed whole, as directed. If the patient chewed the pills before swallowing them, they received the entire 12-hour dose of the drug at once. Crushing the pill and snorting it also worked, and so did dissolving the pill in water and injecting it with a hypodermic needle. The powerful high that resulted—more powerful than heroin—was very addictive.
As the number of prescriptions soared, so did the number of addicts. Studies have since shown that as many as 29 percent of patients prescribed opiates misused them, and as many as 12 percent became addicted, far more than the “less than 1 percent” that had been predicted. An estimated 6 percent of patients who abused OxyContin and other prescription opiates transitioned to heroin when their prescriptions ran out.
Jacques Cousteau’s first dive was in Lake Harvey, VT. He visited there in 1920 as a kid.
And as the number of addicts soared, so did the number of deaths from overdoses. In 1999, 4,000 people in the United States died from drug overdoses. By 2016 the number had risen to 64,000 deaths, with opiates being responsible for two-thirds of overdose deaths that year. (By comparison, 58,000 Americans died in the Vietnam War, which lasted from 1964 to 1975.)
WHO, ME?
For a decade, Dr. Jick remained blissfully unaware of the role his letter was playing in the growing opiate epidemic. He barely even remembered writing it. It wasn’t until 2005, when he was contacted by federal prosecutors building a criminal case against Purdue Pharma, that their subpoena jogged his memory. “I’m essentially mortified that the letter to the editor was used as an excuse to do what these drug companies did,” he told the Associated Press in 2017.
Rather than go to trial, Purdue Pharma cut a deal in 2007 and pled guilty to misleading regulators, physicians, and the public about the addictive risks of OxyContin. They paid $600 million in fines. Three top executives pled guilty to misdemeanor charges of “misbranding” the drug; each of the three was sentenced to three years’ probation and 400 hours of community service, to be served, ironically, in drug-treatment programs. They also had to pay $34.5 million in fines out of their own pockets.
“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,” they wrote.
In 2010 Purdue Pharma reformulated OxyContin pills to make them more difficult to crush into powder or dissolve in water. But the opiate epidemic continues, and the more than two million patients who are already hooked will struggle with addiction for the rest of their lives. They’ll proba
bly have company: In 2016, 236 million prescriptions for opiates were written in the United States; that year, an average of 90 people died from opiate overdoses each day.
PAPER TRAIL
In 2017 some University of Toronto researchers conducted a statistical analysis of all the times the Porter and Jick letter had been cited over the years. They identified a total of 608 citations from 1980 to 2017. Of these, 72 percent used it as evidence that addiction was rare in patients treated with opiates, and more than 80 percent neglected to mention that the patients studied by Porter and Jick were treated with opiates in a supervised hospital setting.
The researchers summed up their findings in a letter to the editor of the New England Journal of Medicine. “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,” they wrote.
Georgia Southern University (Statesboro, Georgia) is home to the U.S. National Tick Collection, the “largest curated tick collection” in the world.
CAVEAT EMPTOR
That letter was published in the June 2017 issue of the New England Journal of Medicine. The journal also took the rare step of giving the original Porter and Jick letter, which is still in the journal’s online archives, something that also appears on bottles of OxyContin: a warning label. Today an editor’s note that appears above the article 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.”
Uncle John's Actual and Factual Bathroom Reader Page 62