<Table 3. Summary of Findings by Period
>
Citing articles from the first period (1986-1996) expressed concern at
the lack of scientific evidence for long-term opioid prescribing. The
articles published in this period were more accurate and affirmational
than the two subsequent periods. Compared to later interpretations of
the index study, these more accurately represented the actual
conclusions and prescribing guidance proposed by Portenoy and Foley.
This was a period of exploration with a focus on increasing the
amount of evidence for opioid prescribing for chronic non-cancer pain.
However, this period of exploration concluded at our identified
breakpoint in 1997. Just a year before, OxyContin® was approved in the
United States, a drug that would go on to define the early American
opioid crisis. What had been a period of exploration quickly
transitioned into a period of implementation during which sales
of OxyContin® skyrocketed from $48M USD in 1996 to $1.1B in
2000.42In this second period (1997-2003), the proportion of empirical articles
reached its highest peak of the three periods. At first glance, this
signifies that concerns about the need for more scientific evidence for
opioids from the first period were being addressed. However, our
qualitative analysis suggests that this empirical research focused
mostly on the efficacy of short-term opioid use, rather than providing
details about long-term effects, either negative or positive. This was
coupled with a rise in inaccurate citations demonstrating that
interpretations began to stray further from the substance of the index
study. In the first exploration period, the index study was being
accurately cited as impetus to seek more evidence for opioid
prescribing, but by this second implementation period it was
increasingly being inaccurately cited as evidence in support of regular
opioid prescribing.
In other words, a push for increased opioid prescribing altered how
scientific evidence was interpreted. In their analysis on the societal
embedding of new technologies, Geels et al. write that “innovators,
entrepreneurs or health advocates try to attract attention from sponsors
and lobby to create a favourable regulatory environment. Product
champions make optimistic, but diffuse promises about future
performance, societal benefits and
profits.”41In this case, the index study was used to make “diffuse promises” that
in many cases were inaccurate. This misinterpretation is most obvious in
how the index study’s recommendation of interdisciplinary treatment was
largely overlooked. While Portenoy and Foley originally noted that
opioids should be prescribed as part of an interdisciplinary treatment
plan with the “concurrent use of ancillary cognitive/behavioural and
physical therapies,” the promised benefits of opioids quickly
overshadowed this recommendation. According to Bernard et al., “what
was intended to be multimodal care, however, became unidimensional care
in most settings with reliance almost completely on pharmacologic
solutions to
pain.”43The prospect of opioids as a one-step solution for chronic pain prompted
governmental and non-governmental organizations to make opioids more
accessible for chronic non-cancer
pain.43This second period showed an increasingly liberal and often inaccurate
interpretation that was associated with increasing opioid-related harms.
Between 2004 and 2019, opioid-related harms increasingly permeated North
American society. Whereas the previous periods explored and implemented
opioids as a solution for chronic pain, this latter period has been one
of concern and reassessment . The number of papers that attributed
the opioid crisis to the index study grew exponentially. Negative
citations also grew significantly, making this by far the most
negational period. As opioids drew more ire from the scientific
community, so too did the index study. This tracks with Geels’ model
that the “peak of inflated expectations” is often followed by a trough
of disillusionment in which “there are some successes with the new
technology, but more
failures.”41This process is exemplified by yet another rise in inaccurate citations
in the third period. However, these now grew alongside attributive and
negational citations. Whereas earlier inaccurate citations were
affirmational and encouraged liberal opioid prescribing practices, these
later inaccurate citations were negational and misinterpreted the index
study as having been a carte blanche for opioid prescribing that
incited the crisis.