Yair Elman, Igor Elman, M.D.

In the era of instantaneous digital information dissemination, online platforms have become pivotal in shaping (mis)perceptions and guiding clinical approaches to the opioid addiction crisis, presenting new challenges and therapeutic opportunities. 

In the late 1970s, an Associate Professor of Medicine at Boston University and a graduate student who were working together on the Boston Collaborative Drug Surveillance Program set out to examine whether analgesic opioid drugs cause opioid addiction.  To that end, they computed the incidence of opioid addiction by extracting data from 39,946 files of patients who were treated with opioids during their hospitalization.  Notwithstanding the absence of even rudimentary methodological section (e.g., patients’ characterization, the nature of post-hospitalization monitoring, types of clinical assessments, psychodiagnostic procedures for ruling the addiction in or out, etc…) the authors concluded that opioid administration in the context of analgesic treatment was not associated with addiction.  The 11-line (5 sentences) Letter to the Editor describing the authors’ findings was published in 1980 in the most prestigious and the highest impact medical journal, namely the New England Journal of Medicine. 

Many of the subsequent 1661 publications (to date) citing the Letter accepted the conclusion at its face value (i.e., confirmation bias) leading to a huge upsurge of opioid utilization across all domains of clinical practice be it inpatient or outpatient.  Fast forward 44 years, we are still struggling with an ominous public health problem with three million people in the US afflicted with opioid addiction like the highly potent synthetic opioid fentanyl, the majority of which are prone to increased morbidity and mortality including 129 daily overdose deaths.

By the way, the true cause of opioid- as well as other addictions remains enigmatic, and it is utterly unclear why a condition with an obvious cure via full detoxification remains so resistant to various interventions.  The theories are abundant.  Yet, an allegory by Leo Tolstoy may be applicable to this sort of conundrum “A locomotive is moving. Someone asks: What moves it? A peasant says the devil moves it. Another man says the locomotive moves because its wheels go round. A third asserts that the cause of its movement lies in the smoke which the wind carries away.  Perhaps Tolstoy also was correct in reckoning that it may be just “necessary to renounce a freedom that does not exist, and to recognize a dependence of which we are not conscious.”  Thus, unraveling the enigma of opioid addiction and reshaping perceptions through rational evidence-based therapeutic approaches may eventually lead us toward a future where addiction is comprehensively understood, effectively managed and even cured.

References

Porter, Jane, and Hershel Jick. “Addiction rare in patients treated with narcotics.” The New England journal of medicine 302.2 (1980): 123.

Dydyk AM, Jain NK, Gupta M. Opioid Use Disorder. [Updated 2024 Jan 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553166/

Tolstoy, Leo. War and Peace. Translated by Louise Maude and Aylmer Maude, Wordsworth Editions, 1993.