My Review of  Drug Dealer MD: How Doctors Were Duped, Patients Got Hooked and Why It’s So Hard to Stop, a Book by Anna Lembke, M.D.

In Drug Dealer MD: How Doctors Were Duped, Patients Got Hooked and Why It’s So Hard to Stop, Anna Lembke, M.D. offers her views on how a failed health care system created the national opioid crisis. According to Lembke, as a young doctor, she never imagined she would be qualified to write a book about addictions. She never intended to be an expert in that area, and she acknowledges that, as a psychiatrist, she was not trained to treat people with addictions. However, she found herself unable to avoid treating addiction when she discovered that many of her patients with mental disorders were inextricably associated with an addiction.

At the beginning of the book, Lembke asserts the Institute of Medicine, in a commissioned report to the U.S. Congress, grossly exaggerated the percentage of the population with chronic pain implying that the necessity of treating pain had also been exaggerated. She admits the actual number of people in pain is significant. Yet she appears to be dismissive of their complaints when she says, “Pain is considered [the emphasis is mine] an almost intolerable sensation to endure.” With that statement, she seems to paint all pain with the same brush when, in fact, every individual’s situation is different. For some patients, pain is, indeed, unendurable. Of the 100 million Americans with chronic pain, 20% of them report persistent disabling pain.

She continues her charge that doctors and healthcare institutions were complicit in creating the opioid crisis. But then Lembke states that corporations “are in cahoots with organized medicine misrepresenting medical science to promote pill taking.” This is a bold statement that calls into question the ethics of many individuals within organized medicine. She goes on to say, “All of health care has become overwhelmed by a hucksteresque opportunism, in which making a buck is the driving force behind practicing medicine.”

This is not a new criticism of our health care system. However, Lembke uses the concept to bolster her argument that physicians who prescribe opioids do so for self-serving, rather than patient-centered, reasons.

Clarification of Points Anna Lembke, M.D. Makes in Her Book

Lembke blames the opioid crisis primary on overprescribing, but she also argues there are other causes. Specifically, she believes four widely held misconceptions led to the opioid crisis. She is correct in pointing out that inaccurate or outdated information may have been problematic. However, these misconceptions tell only part of the story.

The first misconception, according to Lembke, is that opioids are effective for chronic pain. Lembke argues that the lack of long-term studies showing the efficacy of chronic opioid therapy means opioids should not be used for chronic noncancer pain. However, the lack of evidence does not qualify as evidence. To deny opioids as a therapy for chronic noncancer pain on the basis that there aren’t good quality long-term studies may be unfair, and detrimental, to the millions of Americans who believe they have benefited from opioid therapy.

The second misconception is that there should be no limit on how much opioid should be prescribed. She cites an article Dr. Russell Portenoy and Dr. Kathleen Foley published in 1986 in a medical journal, Pain, which said that the dose should be increased until the pain is controlled. This is a true characterization of the prevailing philosophy at the time. Clinicians believed that pain could be controlled in nearly everyone if they just prescribed enough opioid. I remember believing that myself. Along with many of my colleagues, I realized that it was a mistake. Some people just don’t benefit from an opioid, and a higher dosage is not always indicated or safe. However, titrate to effect, as suggested by Portenoy and Foley, remains a well-accepted practice by most experts in pain medicine. The major difference today is the emphasis on ensuring that a dose increase offers a potential for more benefit than risk. This concept existed in 1986 as well, but the understanding of the risks has increased over time. Therefore, the risk/benefit assessment of opioid therapy has shifted from little risk/great benefit to more risk/limited benefit.

The third misconception Lembke points out is that addiction is rare and that opioids usually are not addictive when treating pain. She is correct in saying that the risk of developing an addiction in people prescribed an opioid for chronic pain was underappreciated by clinicians until recently. What she leaves out is that there was not much research data to inform clinicians about the addictive risks of opioids in people with pain. The data that was available suggested that the risk would be very low if opioids were used to treat pain. It is a fair criticism that clinicians, based on the science available at the time, failed to understand the extent of the risk. Specifically, there was some suggestion in the 1990s that pain might be protective for developing an opioid addiction.

Lembke cites rates of addiction of as much as 56% in people prescribed opioids for chronic pain. Other studies have reported a much lower rate of addiction. A review of 26 studies found signs of addiction in 0.27% of the participants, all of whom were prescribed opioids for chronic noncancer pain [Noble et al. 2010]. In general, addiction in the chronic pain population has been difficult to measure. Studies are plagued by inconsistencies in terminology and methodology when defining what is addiction vs. abuse. It is clear that reports vary depending on who is interpreting the statistics. In general, the safest interpretation may be the admission that addiction caused by exposure to opioids for pain therapy can occur, but that the actual prevalence is unknown.

The final misconception that Lembke believes contributed to encouraging overprescribing is the concept of pseudoaddiction. According to Lembke, “…doctors were taught that any patient prescribed opioid painkillers who demonstrates drug-seeking behavior is not addicted, but in pain.” This is not exactly how the term was described or was meant to be used. In 2011, Passik, Kirsh, and I wrote about how the term pseudoaddiction became misinterpreted: “The fact that problematic drug-related behavior can be driven by uncontrolled pain and extinguished with adequate pain control became a fundamental rule of opioid therapy. This led to practices such as escalating doses in the face of noncompliance and has been extended to include behaviors unintended by the original authors.”³ The term pseudoaddiction may have been an appropriate way to describe some behaviors, but the way in which it was interpreted and the way in which it subsequently drove behavior may well have contributed to inappropriate prescribing.

Beyond those misconceptions, Lembke sees other reasons why the opioid addiction crisis paralleled the increase in prescribing opioids. She explains how people addicted to one drug have a much greater chance of becoming addicted to another drug. To support the concept, she discusses how addictions cause irreversible brain damage. She adds that the disease can be easily reactivated during sobriety if a patient is exposed to an addictive substance. Physicians, she implies, have in some instances unwittingly contributed to the opioid crisis by ignoring a patient’s history of substance abuse and prescribed a drug that can trigger addiction. In these instances, she seems to blame the medical education system rather than drug companies.

Lembke explains that an opioid’s addictive properties are more than just the ability to create a euphoric experience. Opioids can allow some people to feel more socially comfortable without experiencing a high. This is another reason for inappropriate use of an opioid. In essence, she describes how anxiolysis can become part of the reinforcing properties that lead to a downward spiral of addiction.

Lembke also writes, “Opioids, doctors were told, needed to be prescribed for all forms of pain, at ever increasing doses, lest the doctors risk engaging in unethical, discriminatory practices.” She is right in saying there was an attempt to awaken the medical profession to the needs of people in pain. There is still a debate about the ethics of allowing people to suffer from pain when there are treatment options. In fact, an organization called Human Rights Watch is investigating whether the rights of people in pain are now being denied as the amount of opioids being prescribed is forcibly reduced by policymakers and the same healthcare systems that Lembke believes created the crisis. However, it is an overstatement to claim that “all forms of pain, at ever increasing doses” of opioids ever were, or would be, the standard of care with responsible clinicians.

Lembke goes on to state that the introduction of pain as the fifth vital sign by the Joint Commission in 2001 was associated with an increase in opioid prescribing. The missing context is that, prior to that time, pain had been ignored and undertreated. The concept of pain as the fifth vital sign served the purpose of alerting providers that pain should be assessed and treated. It is not clear whether Lembke believes that pain assessment — asking people how much pain they are experiencing — should be part of a medical evaluation.

In 2016, in Pain Medicine News, “So, is pain, after all, a vital sign?,” I wrote, “I have argued in the past that it is. But the main point is that assessing pain is indeed vital, whether or not pain is a vital sign. Furthermore, assessing pain as often as vital signs are assessed would seem appropriate. We assess cognitive function, reflexes and laboratory values, none of which are vital signs but are clinically important signs nevertheless.” What is done after the pain assessment matters. Too often, a high pain score on a 0 to 10 scale, with 10 being the worst imaginable pain and 0 being no pain, led providers to prescribe an opioid. The goal was to reach a lower level of pain on the scale. Providers were often treating a number, not the patient, and that contributed to more harm than benefit.

Additionally, Lembke claims, “The FDA contributed to the prescription opioid painkiller epidemic by failing to prevent drug companies from promoting opioid painkillers in the treatment of chronic pain.” It is unclear from this statement if Lembke believes that opioids should not be available for treatment of chronic pain or that companies should simply be prevented from marketing them for the treatment of chronic pain.

The author’s frustration towards people with addiction who attempt to manipulate doctors to obtain painkillers was reflective in her descriptive colorful terms and phrases that include, “Drug Seeking Patients,” “Sycophants,” “Senators,” “Exhibitionists,” “Weekenders,” “Doctor Shoppers,” “Impersonators,” “Dynamic Duo,” “Twins,” “Country Mice and City Mice,” “Bullies,” “Internet Copycats,” and “Little Engines that Could.”

Similarly, Lembke sees pain patient advocacy groups as pharmaceutical-funded front organizations encouraged to seek media attention and “declare national disease-related holidays” rather than as support groups whose members struggle for answers, provide each other with advice. In many cases, these organizations offer hope to those who have nowhere else to turn. Her criticism seems unfair to the majority of advocacy groups that are created to advocate for patients, not industry.

Lembke’s frustration with addiction is apparent and understandable. She works in the trenches where she sees the terrible consequences of substance abuse disorders. But labeling people with addiction and the organizations that support them is not a solution, and it does not address the question of how we can provide the treatment that pain patients, and others who have addiction, need.

In a section titled “When the Compassionate Doctor and the Drug-Seeking Patient Meet,” Lembke raises the issue of mistrust between doctors and patients who need prescriptions to treat their pain. She talks about the defense mechanisms some doctors use with their insistent patients such as passive aggression, projection, splitting, and denial. This is clearly an area in which a psychiatrist has insight and should be enlightening to most readers, including other physicians.

Lembke shares her frustration with the barriers to prescribing Suboxone® for addiction treatment. According to Lembke, that stems “from the consistent discrimination within the US health care system, and on the part of insurance companies, against patients seeking treatment for addiction.” Additionally, she emphasizes that a doctor is obligated to treat addiction. “Refusing to treat patients whom we discover are misusing prescription drugs is not an ethical or helpful response to the prescription drug epidemic,” Lembke says. I agree with her.

Ironically, this is the same line of thinking that, during the 1990s, led to aggressively treating pain. The medical profession considered the treatment of pain to be an ethical responsibility. Lembke’s views of ethical responsibility in treating people with addiction don’t seem to carry over to meeting the needs of people in pain.

Lembke laments the difficulty of sharing information about a patient’s addiction with other doctors because of “lack of timely access to a patient’s substance use history in the electronic medical records.” As a result, Lembke says, doctors are “working at cross-purposes, with addiction specialists trying to get patients off a medication, while other doctors put them back on.”

The lack of education about pain and addiction sets up this conflict. The suggestion that invariably arises is, if you are primarily treating pain, that becomes your priority. On the other hand, if you primarily treat addiction, then prevention and treatment of addiction trumps treating pain.

Lembke states that “addiction treatment needs to be taught at all levels of medical education.” It is hard to disagree. Since roughly 15 percent of the American population experiences an addiction at any one time, it is obvious that addiction medicine should be part of formal medical education at all levels.

In Conclusion

The most powerful part of the book comes in the last chapter where she brings it all together and cites the problems that contribute to the opioid crisis, ranging from a failed health care system and misguided incentives to damaging doctor-patient relationships. The prescription drug epidemic is a symptom of a faltering system, she writes. Lembke concludes by stating: “The most valuable commodity a physician has is his or her relationship with the patient.”

Absolutely. We need to preserve this relationship. We must ensure that doctors will never abandon their patients because of misguided policies that place political considerations and personal biases above the needs of patients. This is true whether you are a doctor who is treating a person in pain or someone who has developed an addiction to the medications used to treat pain.

In my view, Drug Dealer MD: How Doctors Were Duped, Patients Got Hooked and Why It’s So Hard To Stop is not about drug dealing physicians or corporate influences on medicine. It is the story of a doctor who did not plan a career that includes treating an often untreatable disease in a system not supportive and averse to helping people with addictions. It is the story of a doctor trying to understand and seek solutions where answers are few. It is the story of a doctor’s pain at what she sees and can little change. In the end, it is the story of a wounded healer.