Drug Dealer, MD
This past Tuesday, New Jersey got a new governor. I’ve never been a fan of Chris Christie and that was before he called President Obama a “petulant child” during a Republican presidential primary debate. But for all his bombast, Christie had a moment during the presidential primary last year that appeared to have a lasting impact. During a town hall, somewhere in New Hampshire, Christie spoke to the opioid epidemic that had swept the state, personalizing the crisis by speaking about a friend who overdosed on Percocet, after being prescribed the powerful painkiller for back pain. Christie’s friend was just one of thousands of Americans who had died from prescription opioid drug use in the last decade. And yet, I had never heard of the problem before he discussed it on the campaign trail. As it turned out, I was not alone.
The statistics on the opioid crisis are beyond startling. Vox published a comprehensive overview of opioid deaths including a trending graph that should alarm us all. In 2016, preliminary data estimated that drug overdoses killed 65,000 Americans. Unlike previous drug epidemics, this one has cut across races, ages, and income levels. Opioids do not discriminate and they do not require much time to do their damage. But unlike the drug abuse of previous generations, this one began in our doctors’ offices. In her book, Drug Dealer, M.D., Anna Lembke, MD, describes “How doctors were duped; how patients got hooked and why it’s so hard to stop.”
What is the opioid crisis?
My Dad asked me this question a couple of weeks ago when I was in Kansas. He tried to turn the channel during a 60 Minutes segment on the epidemic. A result of a joint investigation between 60 Minutes and The Washington Post, a former DEA official blew the whistle on how the pharmaceutical industry lobbied Congress in 2016 to roll back DEA enforcement mechanisms that could have cut off suspicious drug shipments to clinics that had ordered unusually high numbers of opioids. The sponsor of the House bill, Representative Tom Marino, Republican from Pennsylvania had been Trump’s pick for Drug Czar until he was forced to withdraw as a result of those reports. Senators and House members from states and districts devastated by the opioid crisis were “outraged” that this bill was pushed through without much debate, but the truth is – those who voted for it simply did not do their homework.
So did I grab the remote from my Dad and answer his question? Yes and yes. Let me start by stating the obvious: America is by far the most over-medicated industrialized country on the face of the earth. Our zest for the free-market and hatred of regulation has contributed to our current state but so has our innovative zeal to solve problems and improve human suffering. There is no doubt that our attempts to curb disease and prolong life has led to the influx of pharmaceuticals. It was the overwhelming desire to curb chronic pain that led to the development and marketing of opioid painkillers. Oxycotin and Percocet are a couple of recognizable names but there are many others. Over the last ten years, the number of opioid prescriptions written for chronic pain treatment exploded.
We know what happened next. Patients got addicted. But how? How and why did doctors prescribe medications to which their patients became dependent? Why didn’t they stop? The reasons are complex and multi-dimensional. There is no easy answer and in fact, each explanation builds on each other until you reach a perfect storm; a perfect storm that has left thousands of Americans addicted to opioids or dead because of them.
How did prescription drugs become an addiction epidemic?
Pharmaceutical companies share part of the responsibility but so do many other parties. The first hurdle was convincing the Food and Drug Administration that long-term use of opioids could be used for the treatment of chronic pain without risk of addiction. This was done by adjusting the trial protocols to get more favorable results. Lembke provides a bit of detail but her explanation just makes me want to understand more as the FDA would have had to approve not only the results but the trial’s methods. If the protocols were so obviously subjective and skewed, why would they have been accepted? Do they only look skewed in hindsight? There is obviously more to the story – more than is described here (not that Lembke is not believable or accurate. I just think there has to be more at play here).
The next hurdle was marketing. Here, drug companies did what they typically do with any drug: publicize the hell out of it. They found physicians who were willing to give speeches and lectures at conferences paid for by the drug companies. Those physicians then became “thought leaders” in the medical community and were more effective promoters than the drug reps themselves. Drug companies, in addition to sponsoring conferences in exotic locations and other perks to physicians, spent billions of dollars on television and in online advertising. Patients requested specific drugs that they saw on TV. Doctors who believed that the drugs were safe were happy to oblige.
But pharmaceutical companies provide only one aspect of the supply problem (and I have highlighted only a small part of a much larger industry issue). Added to it is the increasing commoditization and financialization of the healthcare industry. We continue to see this, particularly in our politics. Whenever we hear politicians, currently Republicans, talk about reducing government intervention, increasing competition, and allowing the free market to dictate prices and provide choice, that is what we mean: continuing to turn healthcare delivery into a commoditized service that can be measured and monetized. When we do this, your satisfaction after a visit to the doctor is measurable just as it may be after a visit from the cable repairman.
On one hand, the service provider is focused on quality and delivery of service. But perhaps more importantly, the provider is forced to deliver services in a competitive marketplace in the most cost-effective (read ‘cheap’) way possible. Healthcare services cannot be outsourced or offshored to India and we know from my previous blogs (because I know you read ALL my stuff) that one of the most inflationary aspects of medicine today is prescription drugs, an industry that spends an incredible amount of money on advertising, pitching and lobbying their product. If this is the marketplace, where will costs be cut?
Several weeks ago I decided that I did not give enough of my monthly income to the cable company so I ordered a second box for my bedroom television. Because of where I wanted to place the TV, I had to have an electrician install a new cable outlet. But after hooking up the box, I was irritated to discover that none of the channels worked. After time spent on the phone with “Nicole,” from COX Communications, I hung up with a technician appointment for the next day. Long story short: the actual cable was old and could not handle the new digital signals. I had to have the electrician back to replace it. The experience with COX (the cable company) was excellent. Everyone was courteous; the technician arrived on time, was clean and polite in explaining the issue and next steps. He even wrote out exactly what I needed to tell the electrician. I actually took a picture of the note and texted it to the electrician (Rob). It could not have been easier. COX received good scores on the survey they sent me after the service call.
The healthcare industry, including doctors, are rapidly moving in this same direction. Lembke notes the importance of surveys and numbers to “big medicine.” In the last decade, we have seen a decline in the number of private practices as the number of managed care and integrated systems have risen. Doctors are measured by the number of patients they are able to see each day (read “bill”). In larger practices, one on one time with patients can sometimes be limited to ten minutes. Survey results and online ratings have become more important. Many of us have used them; when I moved to Connecticut, I needed to find a new doctor, dentist, and an optometrist. Friends offer the best and most trusted reference, but sometimes I need a specialist – like a dermatologist or ENT. Online ratings and patient reviews are incredibly helpful. A bad rating or negative review can be a big deal, especially in a competitive market.
At the same time that health care was consolidating to reduce costs, it was working hard to reduce patients’ pain. According to Lembke, the pharmaceutical industry funded pain advocacy groups to lobby and pressure doctors to treat chronic pain. During the intake process, patients were asked, “Are you in any pain? On a scale from 1 – 10, how intense is your pain?” Over time, there became this genuine belief that all pain should be treated and given medication that was safe and effective, there was no harm in prescribing it, right?
Now consider what happens when a patient goes to a doctor for lower back pain and leaves with a prescription for physical therapy and ibuprofen. The patient is very likely in pain – probably a lot of it – and the doctor truly does want to help. He or she knows that they only have a few minutes with their patient and at the time, does not realize that opioids are highly addictive. Limited time, the desire to curb pain, and to avoid a negative rating all lead to that initial prescription which might then lead to a refill or two. By then, the opioid has worked its magic on the neurological sensors in the brain of those most vulnerable and the patient is hooked. But the doctor gets a good rating.
Once hooked, the “addict” takes over
To me, the more interesting part of Lembke’s discussion is how addiction happens in the brain. It is obviously complicated so she breaks it down so even laymen like me can understand it. She explains how the brain adjusts to the “dose” and why the same high requires more and more of the drug to maintain. It is also clear that everyone is at risk of addiction. Nature, nurture, and environment all play a role and each factor is applicable to every race, religion, or region of the country. If this epidemic has taught us anything, it is that no one is immune from opioid’s effect.
One of the more shocking aspects of the author’s story though is the healthcare industry’s response, or more appropriately, the response of physicians. In the past, medical schools have not included “addiction detection and treatment” in their core curriculum. This meant that doctors of all stripes did not know how to recognize addicts’ tactics. Moreover, they did not know the signs and symptoms of withdrawal which typically mirrored those that led to the opioid prescriptions in the first place. For years, there was no national prescription database that collected data from physicians across the country. Without the ability to cross-check, addicts could “doctor-shop” simply moving from clinic to clinic, telling the same story to multiple doctors, all of whom had the same time constraints and rating paranoia. As long as the patient paid cash for the appointment, insurance companies never found out and thus, no checks on the process.
Worse, before the Affordable Care Act (Obamacare) passed in 2010, health insurance companies did not have to cover mental health or addiction treatment. Obamacare established a set of essential benefits, ten to twelve services that every health insurance plan must cover in order to be considered legal. Without insurance or access to treatment, it was difficult for patients who wanted help to get it.
Now all health insurance policies must cover these conditions. The opioid crisis is a primary reason that it was so difficult for Republican senators to “repeal and replace” Obamacare. Republican plans called for the repeal and gradual elimination of Medicaid funding, and it is Medicaid that is primarily leveraged to pay for addiction treatment. In the debates, Republican senators from states hit hard by opioid addiction (Ohio, Pensylvania, Maine, West Virginia and others) were especially vulnerable to constituent pleas to vote against GOP replacement plans because they failed to address the funding needs currently provided via Obamacare. Opioid addiction was not the only reason for the bill’s opposition but it played a significant role in defeating the GOP’s repeal efforts.
Earlier this summer, President Trump promised to declare a national emergency to address the opioid crisis. I believe that at the time he made that statement, he really did not understand what the words meant. He simply wanted to assure the country that he took the crisis seriously. On this, I will give our president the benefit of the doubt. National emergencies are typically reserved for natural disasters and in declaring them, it triggers a release of federal funds. In addition to this ill-conceived announcement, Trump kicked off a commission on the opioid crisis, headed by Chris Christie (and son-in-law Jared Kushner. I put Jared in quotes because Jared is assigned to everything. Christie was the one out promoting the commission and its findings).
After weeks of questions regarding the “national emergency declaration,” President Trump finally declared a Public Health Emergency and announced several steps including a small change in Medicaid policy which could result in a huge benefit to states battling this crisis. I did not quite understand it but a rule mandating a limited number of “Medicaid beds” be allocated to addiction treatment was lifted per the recommendation of the “Opioid Commission.” More beds mean more patients. The administration’s bumbling of the federal response (whether to call it a National Emergency vs. Public Health Emergency) while important, should not diminish the need for action. Trump actually gave a very compelling public address on October 26th. Now his administration needs to follow through with the money and resources necessary to address the problem in a long-term strategic way. And that means that pharmaceutical companies, like tobacco companies, should be held accountable for knowingly pushing drugs when they knew they were harmful.
Prescriptions led to illicit drugs
Once patients’ access to prescription drugs ran out or were cut off, they turned to the black market. Heroin is a natural form of opioid and the oldest; in fact, its use in America date back centuries. Morphine was used throughout the 19th century to treat pain but then as now, it was highly addictive. In the late 19th century, German scientists produced a new iteration called “heroin,” believing it to be non-addictive. They too were wrong but it took years for public policy to catch up. By the 1920s, recreational use of heroin was illegal, but the damage was done. Heroin was used intermittently throughout the rest of the century with a rise in usage during the 60’s and the Vietnam War.
Synthetic opioids (prescription painkillers) are similar to the structure found in natural opium (heroin) and thus when their supply ran out, addicts turned to “regular ‘ole drug dealers” to get a fix. Regular, middle-class, parents found themselves in back alleys doing business with drug dealers. Now the drug of choice is fentanyl, a powerful narcotic that is highly addictive and can lead to respiratory distress and death within minutes of ingestion.
MSNBC has broadcast several special reports on the opioid crisis as have several other networks and media outlets. HBO has a documentary available on demand and online and there are several other short videos you can watch on YouTube and the internet that will give you a better understanding of this health crisis. One book review or news report cannot provide you with a complete understanding of how we got here nor is there a single entity or person to blame (although the pharmaceutical lobby bears a good deal of the responsibility and needs to be held accountable for actions taken to mislead regulators).
The opioid epidemic proves that the “not my kid” mentality is just negligent and naive
Those of us who consider ourselves as part of white middle-class America, and particularly people like me who grew up in a quiet small town tend to become lazy and complacent. Or perhaps I just speak for myself. I was not much of a drinker until I reached my 30s. Prior to that my taste buds just never acclimated to alcohol and I had plenty of other places to spend my daily caloric intake. I guess at some point, my taste buds changed or I found something I liked because I did start to drink more. I loved anything tart. I eventually discovered that orange juice or lemonade satisfied that craving but at the time I guess I was just too dumb to realize that I was forming a habit. Before long, I found myself drinking every night and going to bed with at least a slight buzz. By the time I started going to work with a hangover, I realized I had an issue.
Fortunately, my issue was a habit that could be broken. Honestly, though – it took a while. Thank goodness there was no dependency or symptoms of withdrawal. But I had to figure out what was in the alcohol that made me want to drink it and fortunately, it was not the “high” or that buzzed feeling. Rather, it was just a taste that I could replicate with orange juice (same amount of calories by the way). But while my experience is in no way comparable to the examples of withdrawal that Lembke describes, the experience gave me just a little insight into how easy it could be for anyone, including me, given the right conditions to slip into an addiction.
I would urge everyone to learn more about this epidemic because that is what it is; an epidemic. This disease cuts across all age groups, races, socio-economic levels, and regions. No one is immune to its effects and thus, no one should pass judgment on its victims. This infection can happen to anyone and to any community so yes when politicians start talking about Medicaid and repealing Obamacare, you better pay attention to what that really means. Lembke describes a dozen patients in her book; they come from all walks of life. The lesson is: this could happen to any of us. It could be happening to our neighbors, our friends, or family as we speak. And it could be happening to our kids. Make sure you know what it is and be cognizant of the impact of public policy decisions. While I would not advise overt “paranoia and suspicion,” a basic attention to detail and paying attention to your kids are good ideas. Empathy and stopping yourself from passing judgment are close seconds.