Editor’s Note: This story is a follow-up to a Laboratory Equipment piece published last week concerning a 1980 letter in the New England Journal of Medicine, which was a catalyst for the opioid epidemic that continues to plague this country.

The 100-word research letter that found opioid painkillers were not addictive was published in the prestigious New England Journal of Medicine in 1980. Ever since, it was cited over 600 times by doctors who progressively built upon it to create a branch of the medical literature claiming OxyContin and other drugs were a safe treatment for chronic pain, and not widely addictive. The drugs have since become ubiquitous, and their proliferation claimed more than 183,000 lives from 1999 to 2015.

But it seems that the letter was an unwitting catalyst that was later capitalized upon by researchers who may not have even properly cited it, according to experts.

The doctor who published the five sentences contending there was little to no risk of addiction in a hospital setting is aghast at how his work had been used in ensuing decades.

“I’m essentially mortified that that letter to the editor was used as an excuse to do what these drug companies did,” said Hershel Jick, a Boston University drug specialist who wrote the letter with a graduate student, in an interview with The Associated Press. “They used this letter to spread the word that these drugs were not very addictive.”

The 1980 letter was just the tiny tipping point that started the ball rolling, according to the lead researcher of the bibliometric study also published in NEJM last week, David Juurlink of Sunnybrook Health Sciences Centre and the Institute for Clinical Evaluative Sciences in Ontario.

Juurlink told Laboratory Equipment in an interview that the damage has been done already – it’s now a matter of trying to understand how the letter and its citations came to prop up an entire industry.

The 1980 letter may be just a “curiosity” in 2017, Jurrlink said – but it helps to understand how the how the opioid crisis began to take shape with just a few citations that provided a foundation for an entire pain-killing industry.

“This letter really helped launch the prescribing of opioids – but now we’re at a place where it’s part of routine practice to prescribe opioids very liberally. That’s just the culture,” said Juurlink.

The letter only became available online at the NEJM website in 2010, the researcher added.

“For years, this letter was only available if you went to the library – which is not something most people do,” said Juurlink, who said the pain management doctors like himself were receptive when they were told they could alleviate suffering with wonder drugs of opiates. “We didn’t question it as much as we should have.”

The Jick letter was apparently just intended as a brief look into the hospital rooms at Boston University Medical Center, and see who had gotten hooked on the opiates.

The 2015 book Dreamland by Sam Quinones, a best-selling exploration of the beginnings of opiate epidemic, found that Jick wrote the letter and was helped a bit by then-graduate student Jane Porter. In the book, Jick said he may have been inspired to look at the data on hand at the Boston Collaborative Drug Surveillance Program because he had read a newspaper story around that time concerning painkiller addiction.

The findings from the Jick/Porter letter: out of 11,882 patients who were administered at least one narcotic painkiller, only four got hooked, they concluded.

The letter’s eventual 600-plus citations through March 2017 dwarfs similar research letters, which average about 11 over the same time frame, Juurlink found.

The reason for the citations was that it justified the use of the powerful new drugs – and essentially built a booming market, the Ontario-based researcher said.

“This letter was a critical element of the machinery that was put into place to destigmatize opioids,” said Juurlink. “When you dig down, a lot of the leveraging of that letter is tied in some way to the pharmaceutical industry… I suspect there’s a huge amount of conflict of interest lurking in the background of these citations.”

The fallout continues to spread.

The U.S. has set overdose death records for the last few years running – mostly due to opiates.

Although the official numbers for last year are not yet available, all indications are that the body count is growing. The New York Times published estimates this week showing that 59,000 people or more died in 2016. That death toll means drug overdoses killed more Americans in a single year than gun deaths, car crashes, or the HIV epidemic ever did at their peaks.