The dealer is in
How physicians are fueling the opioid epidemic
When Anna Lembke, MD, began working as a psychiatrist in the late 1990s, she told the clinic’s intake coordinators not to send her any patients with addiction to drugs or alcohol. She did not, at the time, view addiction as a real mental illness, and hence turned such patients away.
What she soon discovered was that she had no one left to treat. Studies show that 50 percent to 75 percent of patients with mood and anxiety disorders are also struggling with addiction to alcohol and drugs. Lembke also discovered that some of her patients were addicted to the very drugs she was prescribing.
Lembke realized that in order to help her patients and not harm them, she was going have to learn how to target and treat addiction — in particular, prescription drug misuse. Her realization happened to coincide with a dramatic increase in prescription opioid misuse across the country. In the United States today, over 16,000 people die each year as a result of prescription opioid overdose.
In her new book, Drug Dealer, MD (Johns Hopkins University Press, November 2016), Lembke weaves case studies with cultural anthropology, public policy and neuroscience to examine the unseen forces driving the epidemic. She concludes that the prescription drug epidemic is a symptom of a faltering health-care system, and calls for reforming health-care delivery for all patients, not just those addicted to prescription drugs.
The following excerpt from Drug Dealer, MD, tells the story of a young woman who became addicted to prescription opioids as a teenager, while under the care of her physicians.
My patient Macy became an opioid refugee. I first met her in the pain clinic where I was asked to assess whether or not she had become addicted to prescription painkillers, and more importantly, what might be done for her if she had. When she first saw me, she was in her early 20s. I was just one stop in a very long road of doctors. As I came to know her, I realized that her story started with the story of her father, Mike. He was her primary caregiver when she became ill in her mid-teens.
Mike grew up poor in the 1980s in the drug-ridden neighborhood of East Oakland, which transitioned in a single generation from a mixed ethnic middle-class neighborhood to a predominantly poor black one, notorious for gang drug warfare. Mike was the youngest of five children, and every member of his family, except Mike and his oldest sister, was addicted to something.
As soon as Mike was old enough, he got out of East Oakland and started a family of his own. He was determined to give his kids a better life, as far away from drugs as possible. He and his young wife moved to a townhouse in Fremont, a middle-class community south of Oakland. They had two daughters: first Katherine, and then, seven years later, Macy came along. Their life was complete.
When Macy was a junior in high school, she began experiencing unbearable leg pain. Mike, to whom she had always been especially close, wasn’t sure what to make of it and assumed it was growing pains, so did nothing. But a month later, Macy collapsed while playing volleyball at school and was rushed to the nearby emergency room. The doctors performed a number of tests and couldn’t find anything wrong with her. Despite the absence of any pathology, they gave her intravenous morphine to treat the pain and sent her home. Two weeks later Macy was back in the emergency room with the same pain. More tests revealed an unusual mass on her diaphragm and on her ovary. The doctors worried it was cancer, and they switched from intravenous morphine to intravenous Dilaudid, and she was admitted for surgery to remove the tumors. As it turned out, the mass on her ovary was a teratoma, a benign growth of no consequence. The mass on her diaphragm was a bit of lung tissue, also benign, the resection of which was more involved and required yet another hospitalization and more surgery. The doctors hoped the removal of the masses would eliminate Macy’s pain, although a relationship between the masses and her pain had never been clearly established. In the meantime, she was given intravenous morphine, Dilaudid and hydrocodone, all potent opioids with addictive potential, during and after each surgery. Altogether, Macy was hospitalized for two months, October and November of 2010, and barely remembers any of it because she was so altered by prescription painkillers.
At no point in the course of Macy’s medical procedures was the risk of opioid addiction discussed. Nor was Macy’s family history of addiction considered relevant. When Macy’s various surgeries were complete, her doctors declared that she should be pain-free. Despite having received heavy doses of opioids daily in the hospital for two consecutive months, Macy was sent home without a single pill. For the next six weeks, she experienced excruciating opioid withdrawal — nausea, vomiting, fever, chills — as well as unbearable muscle and bone pain throughout her body, even worse than the original leg pain.
In the grips of opioid withdrawal, Macy would lie on the floor screaming and crying out. Her parents, unsure what else to do, took her back to the local emergency room every few days, where she was given the opioids her body craved and promptly discharged again. Sometimes the doctors would readmit her to the hospital and give her intravenous morphine to control her pain, then discharge her again without opioids, follow-up or any semblance of a treatment plan. Between 2012 and 2014, Macy’s parents took her back and forth to the emergency room in an endless cycle of despair and frustration. The doctors never seemed able to tell them what was wrong with Macy, or how to help her, except for writing more opioid prescriptions.
Then, in 2014, on one of the emergency room visits, the doctor came out of the room and said to Mike with barely veiled hostility, “Is your kid on drugs?” He was implying street drugs like heroin, not the painkillers Macy’s doctors were prescribing, although chemically speaking there is almost no difference between the two. Would his reaction have been the same if Macy were white instead of black?
“No,” said Mike, without a moment’s hesitation. “How do you know?” challenged the doctor.
“I know because I know my daughter, and because we’re with her all the time, and because she’s not hanging out with other people doing drugs.”
“Your daughter is a drug addict,” the doctor said. “Don’t come back here for pain medicine again.”
Mike said nothing. He was without words. He gathered Macy up in his arms and drove her home. When he got her there, she lay on the floor, moaning and crying out.
“Give her some pain pills,” he said to his wife and daughter Katherine, who were looking on helplessly.
“They’re all gone,” said his wife, a pleading look in her eyes. “Dammit,” Mike shouted. He wanted to shut his eyes and make it all go away. Then he made a decision.
“That’s it,” he said, grabbing his car keys. “If those doctors won’t help her, I will.” Without another word, he left the house and got in his car. He headed back to the old neighborhood, silent tears streaming down his cheeks. He still had some old friends who sold drugs. He would find them and buy some Percocet, or some heroin if he had to. That would stop Macy’s pain.
As Mike was driving, a memory from his childhood intruded on his thoughts. He was crouched at the base of the chimney in his childhood home, tracing the outline of the inner brickwork with his chubby fingers, looking for the hole between bricks where the mortar had long ago crumbled away. He felt the divot and shoved his fingers inside, hoping for the crinkle of plastic. He found it. He pinched his fingers to get a hold of the bag and slowly pulled it out.
“Mommy, Mommy,” Mike called, “I found one!”
He ran to the kitchen holding the plastic bag in front of him, the little blue and red pills bouncing around inside of it.
His mother was cleaning the kitchen, tired after working one of the many jobs she had over the years — housecleaning, cooking at a local diner, working the line at the Del Monte Cannery, forklift driving. Mike was her fifth child, with a different father than the rest, her child of that no-good drunk she sent away the day Mikey was born, knowing in her heart he wasn’t going to be the father her son needed. She dried her hands on her apron and folded the little boy in her arms.
“You found one, so you get a dollar from me,” she told him, “just like I promised.”
She reached inside her purse and handed him a dollar bill.
“Now you listen to me,” she said, kneeling down and looking him in the eye, “I don’t want you ever doing those drugs like your brother and sister. It’s no good, no good.
“I won’t Mama,” he said, “I promise. I don’t ever want to make you cry.”
As if waking from a dream, Mike took the next exit off the freeway, turned the car around, and drove home again. When he got home, he bundled the still crying Macy back into his car and took her to a different hospital emergency room. After hours of waiting, the doctor finally came. Mike turned to him and said, “This is my daughter Macy, and she has terrible pain all over her body which no one can understand. She is also addicted to pain pills, and doctors made her that way, so don’t turn your back on her. Don’t judge her. Help her.”
This new doctor, perhaps humbled by Mike’s desperate admission, took Macy in and admitted her to the hospital, using the occasion to get her a treatment plan that included assessment and treatment for addiction, which had never previously been suggested or offered and which is how she eventually ended up with me.
Once in addiction treatment, Macy’s problems did not magically disappear, but with time, patience, courage and effort, Macy made her way slowly to a better place, with decreased pain, improved function, a job and plans for the future, which Macy also deserves.
The above excerpt is taken from Drug Dealer, MD, by Anna Lembke, MD. Published by Johns Hopkins University Press © 2016. Reprinted by permission of the publisher.
In this 1:2:1 podcast, Stanford psychiatrist Anna Lembke, MD, discusses how physicians have fueled the opioid epidemic — and how we are going to get out of it.