Book Review: “Drug Dealer, MD” by Anna Lembke, MD

I hated the title but loved the book.

I imagine some marketing hack told the author she needed a title that would grab people, and this is what they came up with. The book doesn’t talk much about the few doctors who turned out to be drug dealers. Rather, the book tells the story of pain pill addiction in our country, about how it happened and the contributing factors. Most importantly, it discusses how to prevent opioid use disorder and how to treat the patients who developed opioid use disorder.

I like this book because it’s concise. The author succinctly presents data without getting wordy or going off on too many tangents. Even with so many other competing books on the market, this one stands out. Published by Johns Hopkins University Press, it only runs to 152 pages. But since it was published in 2016, it missed the last few years of our opioid epidemic and how patients have switched to heroin, now that pain pills are scarce.

The author uses some patients’ stories to underline points of information in the book but doesn’t overdo this. Her first chapter is about the nature of addiction, with descriptions of risk factors for initiation of substance use, and risk factors for the development of substance use disorders.

In Chapter Two, the author told about the overprescribing we saw in this country, beginning at the end of the twentieth century. She described how the internet functioned as a supplier, though most other experts say the internet wasn’t a prominent driver of the opioid epidemic in its early years.

By Chapter Three, the author, a well-known and respected Addiction Medicine specialist, expressed interesting ideas about the role of “illness narratives” in some patients. By this term, she means some people with physical and psychiatric differences get labelled as having an illness, rather than being accepted as normal human variations. She uses the example of back pain, which she says in the past might have been looked at as a normal part of human existence, which now is termed a chronic pain disorder. The implications of the illness narrative are that pain should be viewed as something dangerous that must be got rid of, rather than endured, exposing the afflicted person to the dangers of opioids and opioid use disorder.

As an example of psychiatric differences, she uses the normal human tendency to become distracted, which in an extreme form is now labeled as an illness: Attention Deficit Disorder. This label of illness, she says, implies the need to medicate the condition. This illness becomes part of the person’s identity and thus their “personal illness narrative.” She says it’s tempting for people to blame their illness as the cause for life’s failures and disappointments.

Later in the book, in Chapter Six, she describes the dilemma of people who have adapted an identity of an ill patient, calling them “professional patients.” She makes a case that people who have been granted disability benefits have a financial incentive to stay sick, in order to maintain their benefits. They may become so psychologically attached to their role as a sick person that the thought of recovery and wellness is frightening.

Most of all I enjoyed reading Chapter Four, titled, “Big Pharma Joins Big Medicine.” She did an excellent job of skewering Big Pharma’s great deception: marketing which masqueraded as education. Big Pharma identified physicians they could influence to parrot Pharma’s lies and coronated them “thought leaders.” These professionals were paid speakers’ fees to give talks to other prescribers, extolling the benefits and lack of risks of opioids.

What hard-working and underappreciated doctor wouldn’t be flattered to be called a “thought leader?” Along with hefty speaking fees, I can see how pharmaceutical companies seduced some physicians, encouraging them to present Big Pharma’s message about how safe opioids were for chronic pain treatment, even though there wasn’t data to support those claims.

In a few paragraphs, the author succinctly describes how the FDA failed to prevent drug companies from marketing opioids for the treatment of chronic pain, despite the lack of studies about safety. She also deftly describes a new study technique that’s bound to skew data about opioids, called “enriched enrollment.”

Then in Chapter Five, the author describes stereotypic behaviors of patients who try to manipulate doctors into prescribing the medications that they want. The author prefaces these behaviors with a sentence saying the terms aren’t meant to denigrate drug seeking patients, but that’s exactly what she proceeds to do.

For example, she describes patients who try to filibuster and talk past the allotted time for the appointment as “Senators.” She describes patients who flatter doctors by telling they are so much wiser/compassionate/competent than any other doctors as “Sycophants.” Other patients are described as “Exhibitionists,” who display dramatic emotions and physical scars to underscore dire need for opioid medication.

I recognize all these behaviors, both in patients I see with substance use disorders and in primary care patients; however, to place labels on the behaviors of people caught up in the desperation of active addiction is unseemly. The book would have been better if this section was omitted. However, in that same chapter, the author neatly summarizes the basic principles underlying the treatment of opioid use disorder with methadone and buprenorphine.

Chapter Eight was the most interesting. This chapter is titled, “Pill Mills and the Toyota-ization of Medicine.” In this chapter, the author talks about physicians who work at pill mills, who have long ago given up the illusion of working to help people. They are in a business to give pain pills to people who want them, no matter if it’s in the patients’ best interest, in order to make a lot of money for themselves.

But then she starts talking about how medicine has become a business, and that pill mills are only extreme examples of how medicine has changed into an industrial business. Physicians have less autonomy as their practices are bought by hospital corporations. Treatment options for all illnesses are more often determined by hospital administrators, insurance companies, and treatment guidelines promulgated by agencies like the Joint Commission (used to be called JCHCO).

Doctors are expected to meet productivity quotas and see ever more patients in a day. I’ve heard practice administrators use the euphemisms “practice maximization,” and “increased patient throughput.” The author of this book describes how she was given monthly feedback about whether she was hitting the billing targets that had been set for her. If she wasn’t meeting these targets, set by her employers, she had more to worry about than caring for her patients.

Giving patients what they want is the quickest way to get on to the next patient, further exacerbating overprescribing. It takes much less time to write a prescription than to talk to the patients about non-opioid ways to treat pain, and about the emotional issues that make pain worse. And this applies not only to opioids, but other medications. What physician hasn’t buckled at least once to the demands of a patient insisting that a Z-pack always gets rid of her viral illness? It’s easier to write the damned prescription than it is to have a conversation about how antibiotics don’t work for viral illness, and how inappropriate use of antibiotics causes antibiotic resistance.

I commiserate with the time pressures she describes.

On my 40th birthday, nearly two decades ago, I was told by a practice administrator that I was too slow. I was “only” averaging six patients per hour, and I’d have to pick up the pace if I wanted to keep working there.

Driving home that evening, I was shaking with anger and fear. I knew I couldn’t deliver quality care seeing more than thirty-six patients per day. I felt defective, like there must be something wrong with me because I couldn’t (or wouldn’t) keep up the pace of my colleagues.

I made up my mind that I needed to look for some other type of work in the medical field. I told my physician friends I was open to new ideas, and a few months later I was asked to fill in for a friend who was going on vacation. He was the medical director of an opioid treatment program. Deeply skeptical at first, I eventually found this to be my niche. It’s intensely satisfying to work with patients and see the tremendous life changes that I never saw while practicing primary care.

I feel sorry for doctors who never found their way out of the production line. I’m not saying opioid treatment programs never push providers to see more patients in less time, but I haven’t experienced near the pressure in OTPs that I have working in primary care.

The author then talks about another driver of the opioid epidemic: patient satisfaction scores. Many medical practices conduct surveys of patients after visits, to get feedback on what patients like and what they don’t like. They are asked about their physicians.

 Initially, these surveys were said to help providers pivot to a more patient-centered frame of mind, to sensitize them to patient concerns. Now, patient satisfaction scores are considered a “quality measure.” Providers with higher patient satisfaction scores are assumed to have provided better care, despite some evidence to the contrary. Physician pay is often linked to these satisfaction scores, giving doctors another reason to prescribe what the patient wants rather than take the time to have a difficult discussion about substance use disorders. Providers know giving patients what they want gives better satisfaction scores, and indirectly, better pay for themselves.

Then there’s the whole internet “Grade your doctor” websites. The author describes her trauma of reading a bad review online that was found by her son, and her angst in wondering who it could be who left such unkind remarks about her as a physician.

Back when there were one or two sites for physician grading, the internet could have been a factor that had an impact, but now there are at least twenty sites for this. I think this dilutes the effect of any one site, reducing the influence they have.

In Chapter Nine, titled, “Addiction, the Disease that Insurance Companies Still Won’t Pay Doctors to Treat,” the author describes the problem that persists in the U.S., despite passage of the Parity Law in 2008. The Parity Act, which said substance use disorders and mental health disorders must be covered by insurance companies to the same extent as other medical illnesses, has not assured equal coverage. This is a frustration that most providers of care to patients with substance use disorders face daily.

Though coverage for medical care of substance use disorders isn’t great, coverage for the medical complications of those disorders is much better. The complications of intravenous drug use, for example – endocarditis, osteomyelitis, cellulitis – are usually covered if the patient has medical insurance. Yet most medical insurers still don’t cover care delivered at opioid treatment programs or cover it poorly.

In the last chapter of the book, the author gives reasons to hope that our nation’s opioid problem may improve at some point. She points to better education of medical students, residents, and practicing providers about prescribing skills. More providers in training are being taught addiction medicine basics, and addiction medicine fellowship training programs have been started.

She hopes substance use disorders will be viewed as the chronic illness that it is, rather than a moral issue or a short-term medical problem. She says providers need to be allowed to spend more time with patients to give better care. She describes new models of care for patients with chronic pain, using both non-opioid medications and non-medication treatments, which have been successful.

I really wish she would have re-iterated the benefits of medications in the treatment of opioid use disorders in that last chapter. But at least this author did write three pages about the benefits of medications like methadone and buprenorphine in the middle of the book, and that’s more than most of the recent popular books about opioid use disorder have done. I thank her for that.

But then…she is an addiction medicine specialist, so maybe I’m justified to be a bit disappointed by this.

But this book is succinct, the data is accurate, the patient stories typical for many patients, and she does a wonderful job of documenting factors that merged to cause our present opioid problem.

For any person interested in opioid use disorders, I strongly recommend this book.

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