Q & A: Hidden forces behind the US prescription drug epidemic

After noticing more and more patients in her practice struggling with prescription drug addiction, psychiatrist Anna Lembke, MD, investigated the problem of rampant overprescribing in the US medical community and the hidden forces encouraging it. Her resulting 2016 release, Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop, became an influential bestseller. Health Affairs deemed the work a “thought-provoking book [that] should be a must-read for medical trainees, providers, and health policy leaders working at the forefront of addressing the prescription drug epidemic.”

Associate professor of psychiatry and behavioral sciences at Stanford University School of Medicine, California, Lembke will present a featured session at the upcoming Psych Congress conference. She recently talked with Psych Congress Network about the state of the US prescription drug epidemic, our modern-day aversion to pain of all forms, and how her medical colleagues have reacted to her book’s provocative title.

Q: Is there any good news with the current state of the opioid epidemic, or is the situation still especially bleak?

A: The good news is that opioid prescribing in this country has decreased by approximately 20% relative to its peak in 2012. Efforts to re-educate doctors and implement policies to curb overprescribing have had an impact.

The bad news is that we are still prescribing three times as many opioids as we did in the 1990s, four times as many as are prescribed in Europe, and more than 10 times as many as in Japan. Europe and Japan are apt comparisons because they are also rich areas with aging populations and comparable needs for analgesia.

In other words, although we’ve made progress, we still have a long way to go.

Q: Since the publication of Drug Dealer, MD, you’ve consulted with lawmakers and other officials looking to stem the opioid epidemic in the United States. What led you to become an authority in this area and then to write this influential exposé on the causes of opioid addiction?  

A: In the late 1990s and early 2000s, I was seeing more and more patients in my practice struggling with addiction to opioids and benzodiazepines prescribed by their doctors. I myself was also prescribing benzodiazepines and stimulants too liberally without recognizing I was harming my patients. When I realized there was a problem and tried to alert my colleagues, I met strong resistance, even among well-educated, compassionate, and well-intentioned healthcare providers. That made me curious about what I now recognize as the invisible forces inside medicine that can cause even a good doctor to provide bad care.

Q: What surprised you in your research for the book? 

A: I was astounded by how much the pharmaceutical industry has a hand in dictating standards of medical care. Their outsized influence on what is hailed as “evidence-based medicine” was a huge factor in creating the prescription drug epidemic we face today. For example, The Joint Commission, which confers the gold standard approval that hospitals need for Medicare reimbursement, acquired opioid propaganda for free from Purdue Pharma [the maker of OxyContin] and sold it to hospitals trying to meet the new Joint Commission quality measure of “pain as the fifth vital sign.” Not only did the Joint Commission profit from this strategy, but it also perpetuated the myth that opioids were being underprescribed.

Q: The title of your book—Drug Dealer, MD—is certainly attention-grabbing. As an MD yourself, were you comfortable with the title? Do you find medical professionals generally accept their role in the current opioid crisis, or do they tend to get defensive at the “drug dealer” tag?

A: The title has been a double-edged sword. It’s the same title I used for early drafts of my manuscript, so I kept it when I submitted my final copy. My editors liked it because it’s attention-grabbing while also capturing the major theme of the book: the problem of rampant overprescribing.

On the other hand, the title has been off-putting for some readers, especially physicians who believe, mistakenly, that I’m blaming doctors. In fact, the whole point of the book is to demonstrate that doctors have been victims as much as patients, caught up in a system in which they have limited control over how they practice medicine and are forced to practice in ways that don’t align with their values. I’ve had physicians tell me they didn’t want to read the book because they were dismayed by the title but, after they read it, realized there is little or no doctor- blaming. The subtitle, How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop, is in many ways a better description of the book than Drug Dealer, MD. But I don’t regret the title. I think it’s the right title for this book at this particular time in history.

I’ve gotten pushback from healthcare providers about my message and hate-mail from doctors and patients alike. But my message, which was radical at first, is now pretty well accepted: opioid overprescribing has been a major cause of the epidemic, caused not just by pill-mill doctors but also by a wholesale paradigm shift in how we treat pain.

Q: Can you talk about how our view of pain has changed over the centuries?

A: The modern medical view of pain stands in stark contrast to how pain was viewed 150 years ago. Today we believe pain in all its forms is dangerous and can leave patients with a psychic scar that sets them up for future pain. As such, it has become the role of the medical doctor to eradicate all pain at any cost. But doctors used to believe that pain was salutary, that it expedited healing and conferred spiritual benefits.

I certainly don’t believe in leaving people in pain out of some gratuitous, sadistic impulse. But the reality is we’re not much better today at treating chronic pain than we were 50 years ago. And in our efforts to eliminate all pain with opioids, we have done our patients more harm than good.

Since we can’t eliminate all pain, we have to teach our patients how to achieve some quality of life, even with pain. We have to think about the long view, not just what will help them feel better today.

Q: When it comes down to it, who is to blame for this epidemic? Did Big Pharma just want to sell more drugs and make more money?

A: The whole point of my book is that no single person or institution is to blame. Opioid manufacturers played an important role, but they were propagating falsehoods that turned out to be convenient myths for doctors with too many patients, too little time, and a reimbursement structure that favors prescribing pills and performing procedures over talking to and educating patients about their health. Cultural factors also played a role, having to do with patients’ unrealistic expectations about how much pain is too much pain and what doctors can do to help.

Q: What are some of the major barriers to turning around the epidemic?

A: Barriers include the perverse incentives inside of medicine driving overprescribing, and the lack of infrastructure in the House of Medicine to target and treat addiction.

Q: How do you suggest mental health providers address the issue of opioids in their daily practice?

A: It’s essential to go beyond the single data point of what the patient tells you about how opioids are affecting them. Because opioids work on the brain’s reward pathway in addition to pain receptors, patients are liable to overestimate the benefit of the drug on pain relief and functionality. Therefore, getting other data points becomes crucial.

Talk to family members and significant others who have the opportunity to observe the patient in their daily lives. Data show family members are concerned about opioid misuse and addiction even when the patient isn’t. Check the prescription drug monitoring database before initiating any controlled drug and then every three to six months after. Patients can insidiously develop problems over time, even with no history of drug misuse or addiction. If an opioid misuse problem is detected, don’t fire the patient. Instead, put opioid misuse/use disorder on your problem list, discuss the problem with the patient, and triage them to the right kind of care.

Q: Amid all the sadness and enormity of the epidemic, is there a place for hope?

A: There’s always reason to hope, and the opioid epidemic is no exception. The silver lining of the epidemic is that it has raised national awareness inside and outside of medicine about the problem of addiction. Local, state, and federal entities are putting unprecedented resources toward the problem, and people across ethnic and sociopolitical divides are engaging in discussion about the problem.

With increased awareness and dialogue, we are reducing stigma and improving access to treatment for those who need it.

Q: Do you have any additional advice for mental health providers wanting to truly help their patients?

A: Don’t be afraid to ask your patients about substance use problems and other addictions like gambling, gaming, or sex. If you ask, you will be amazed at how eager they are to talk. You will also be impressed by how much you are able to help, just by opening a dialogue.

For far too long we as a field have ignored the problem of substance use and addiction, preferring to talk about every single childhood memory before asking simple questions about drug and alcohol use. In that regard, many of us, including myself, have been complicit in perpetuating the problem. It’s time to shine the spotlight on addiction and do our part to help, and that includes all of us, not just those working in specialty addiction treatment.

I believe that addiction is and will be the single most important public health problem of the 21st century. Mental health providers across the board have an important role to play in helping to find solutions.

This story originally was published by Psych Congress Network, a sister publication of Addiction Professional.