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Winter 2018

The Making of an Epidemic

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Toni Martin

Drug Dealer, MD:
How Doctors Were Duped, Patients Got Hooked
and Why It’s So Hard to Stop
by Anna Lembke.
Johns Hopkins University Press, 2016,
$19.95 paper.

A fellow internist I bumped into at a medical conference recently—a man I met during our residency training forty years ago—told me he had retired.

“A year ago,” he said. “And the patients are still forging my name on Vicodin prescriptions.”

I laughed, but it wasn’t funny, to either of us. How did we end up here? We had both done what we set out to do, primary care medicine. But somehow that turned out to be a fool’s errand in a medical system where insurance paid for procedures, not disease management, and we ended up arguing with patients about pain medicine prescriptions. Rather than laughing, I wanted to express my empathy—say that I, too, felt like I had been rolled. Many of us in practice when the opioid epidemic took hold could never quite understand what had happened. But he was off to one lecture, I to another.

If I ran into him again, though, I would be sure to recommend chapter four of Anna Lembke’s excellent book, Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked and Why It’s So Hard to Stop. She’s a psychiatrist, chief of addiction medicine at Stanford, who entered practice after the increase in heroin use and fatal overdoses was recognized as a public health emergency. She emphasizes how she had no training in addiction medicine and did not set out to specialize in this problem. She had the courage to respond to patients who were asking for her help. I say courage, because most psychiatrists don’t want to deal with addicts. No one does.

Lembke’s book is addressed to the lay reader, so she starts with definitions and anecdotes that explain the issues to those with no medical background. But chapter four, “Big Pharma Joins Big Medicine,” is the one that sets out how the leaders of the medical profession and our regulatory agencies were bought off. You would think, as a doctor, that I might have figured this out on my own. But in 1996, when Purdue Pharmaceuticals introduced OxyContin, the gateway narcotic to our present nightmare, I was in a sheltered prescribing situation at Kaiser Permanente. Doctors at Kaiser did not see representatives of pharmaceutical companies at all, because they were not allowed to come to our offices. We also practiced with a closed formulary, so that we could only prescribe medicines on the approved list. A pharmacy committee vetted new medication for efficacy and value. They were particularly vigilant to avoid new, expensive, “me-too” drugs that were no more effective than older generics.

During my years at Kaiser, which in retrospect appears a time of innocence before opioids dominated pain treatment, I was trained to work in the back clinic. Initially, I trailed behind a petite doctor in her fifties, watching her examine and counsel patients. She didn’t recommend narcotics. When she talked about back exercises, she lay down on the linoleum floor in the exam room and demonstrated them. The patients were astonished, and so was I. From then on, I showed my patients the exercises, too. It was worth the look on the patient’s face each time: “Whoa, this old lady is serious about these exercises.” And I still believe that treatment of musculoskeletal pain hinges on correcting body mechanics, preserving range of motion, regaining strength.

Purdue marketed OxyContin as less addictive and less subject to abuse because it was a new long-acting formulation of oxycodone. In 2007, Purdue Frederick Company pled guilty to criminal charges of misleading physicians about OxyContin, accepting fines of $634 million. Lembke outlines how Purdue targeted physicians, wining and dining us at pain-management and speaker-training conferences. The company mined prescribing data to find the physicians who wrote the most prescriptions for narcotics, and invited those doctors to Sunbelt resorts. They selected certain academic physicians to be “thought leaders” and sent them all over the country to tell us that we were undertreating pain, and to reassure us that as long as the patients complained of pain, the risk of addiction was very low. They urged us to consider narcotics for all severe pain, even chronic musculoskeletal pain. Prescriptions of OxyContin for non-cancer pain skyrocketed from 670,000 in 1997 to 6.2 million by 2002.

If the only problem were that doctors were misled by aggressive marketing, the Purdue settlement and the Sunshine Act (a law that makes public any drug company payments to individual physicians) might be the end of the story. But most of us had no contact with Purdue and received no money. We learned a new way to treat pain from academic physicians, from legislation, and from our licensing boards, sources that we considered reliable. Many of us questioned this new wisdom. We had little experience prescribing narcotics for non-cancer pain, because we were trained not to. In private practice, doctors uncomfortable with large doses of narcotics sent patients to newly minted “pain specialists,” usually anesthesiologists, who were happy to supervise chronic narcotic regimens in addition to their more lucrative procedures (epidural injections for back pain, nerve blocks). The rest of us adapted as best we could to the new guidelines.

As far back as 1994, the Medical Board of California released a statement that signaled a new attitude toward the treatment of pain. “Pain management should be a high priority in California… The Board believes that addiction should be placed in proper perspective… Concerns about regulatory scrutiny should not make physicians who follow appropriate guidelines reluctant to prescribe or administer controlled substances.” We doctors routinely read the Medical Board’s newsletters mainly for gossip, to learn who in our community had their license suspended or revoked for bad behavior. But here they were saying that we should loosen up, prescribe a little more, almost promising to look the other way if we documented the visit.

The Pain Patient’s Bill of Rights passed the California legislature in 1997, one year after OxyContin’s debut. It makes for sober reading in light of the opiate epidemic. “Inade-quate treatment of acute and chronic pain originating from cancer or noncancerous conditions is a significant health problem,” it says. “A patient suffering from severe chronic intractable pain has the option to request or reject the use of any and all modalities to relieve his or her severe chronic intractable pain.” Physicians could refuse to prescribe opioid medications, but we had to inform the patient that there were physicians who specialized in the treatment of pain with methods that included opioids.

Even the original label the Federal Drug Administration approved for OxyContin stated that addiction was “very rare” if narcotics were legitimately used in the management of pain, and that the delayed absorption of OxyContin reduced the abuse liability of the medication. The FDA is a government agency, not a drug company, yet it was using the Purdue marketing language, which was based on very limited studies. No one can predict who will become addicted to pain medication, even now. In 2001, the FDA changed the label to reflect the information already coming out about abuse of OxyContin, but by then the damage was done.

Also in 2001, a new law in Califor-nia required all physicians except pathologists and radiologists to take twelve hours of continuing education in pain management and terminal care. It’s a one-time requirement, and twelve hours is not very much, amortized over a forty-year career. My course seemed reasonable at the time, although I don’t remember the details. But there is no similar law for any other area of medicine. (For many physicians, like pediatric dermatologists, the subject was irrelevant to their practice.) And the underlying assumption was that all pain should and could be treated with medication.

On another front, the campaign to assess pain as the fifth vital sign in the hospital took off in the late 1990s, with the Joint Commission, the hospital accreditation body, publicizing this concept in 2001. The idea was to assess the level of pain as frequently as the patient’s blood pressure. If the patient didn’t speak English, she could point to a picture of a person grimacing in pain. It has been reported that the Joint Commission even distributed a pamphlet produced by Purdue that played down the risk of addiction. The Commission hasn’t addressed that specific charge, but they released a statement last year denying that their standards contributed to the opioid epidemic.

The problem is that unlike the other four vital signs—blood pressure, heart rate, temperature, and respiratory rate—pain is not something that the nurse or doctor can measure. It is a subjective judgment, based on the patient’s self-report and so-called “pain behavior.” I don’t feel your pain: I can’t. Patients who want narcotics become excellent actors. During one of my earliest years in practice, an agent from the Drug Enforcement Admin-istration called to warn me that a man who had come to me with a biopsy report of kidney cancer, saying he had to change doctors because he was now on Medicaid (a common problem), had forged the report, was faking his pain, and had already been to several doctors in the area. At the other extreme, a patient with a ruptured appendix and a rigid abdomen assured me that he didn’t need treatment—because, it turned out, he was undocumented and feared hospitalization.

There are patients too busy for pain who want to substitute pills for self-care, and others not busy enough, who offer to show me minute-to-minute journals of pain severity. Labor and Delivery is a great place to observe international norms for pain behavior: there are the silent cultures and the screaming cultures. It’s not easy to figure out who’s “really” in pain. Once patients began to expect and request narcotics—“Give me the good stuff, Doc. Motrin doesn’t help me at all”—my job felt much harder.

Lembke offers a psychiatric theory about why we doctors find it difficult to negotiate with patients about pain. She says that we are “pleasers,” who make it through school by figuring out what other people want and giving it to them. Facing a drug-seeking patient makes us anxious because we define success by mutually affectionate interactions with patients. We deny signs that our patient may be abusing opioids to avoid confrontation. (I would add that it’s always quicker to write a prescription.)

About five years ago, the clinic where I worked instituted mandatory urine testing for everyone who took any opioid for longer than three months. “But what about our little old ladies with bad arthritis?” we doctors moaned. “Do we really have to test them?” The answer was yes, because it turned out that their urine was often clean. In other words, they weren’t taking the Vicodin themselves, but selling it to supplement their fixed incomes. It was just a matter of supply and demand, of course, but when the results came back, we were both surprised and saddened.

Purdue hijacked the entire regulatory apparatus of the medical profession so that even doctors like me, who barely knew that OxyContin was on the market, ended up prescribing more pain medication than we had before. Some doctors still argue that wider prescribing did not cause the opiate epidemic. It’s true that not every patient tries heroin when the Oxy-Contin runs out. But I think you’d have trouble finding a primary care physician in practice during the Nineties who doesn’t believe we contributed to the problem. We endorsed a fantasy: the end of pain.

Lembke outlines what steps we can take to cope with addiction in our practices, but she also admits, “There is an unspoken tension underlying the hidden forces driving the epidemic: doctors are increasingly asked to care for people with complex biopsychosocial problems (nature, nurture and neighborhood) without also being given the tools, time or resources to accomplish this task.” Medical students complain that primary care has devolved into social work, but is it social work to search for root causes rather than simply prescribe or cut? Dr. Francis W. Peabody, a prominent physician in the early twentieth century, wrote, “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”

My generation is close to retirement. Our younger colleagues, inundated with the tide of fatal overdoses and addiction across the country, don’t have time to mull over how we got here. Lembke keeps her focus on the opioid epidemic, but by documenting the influence of the pharmaceutical companies in this case, she offers a broader warning. We are still just as vulnerable to lobbying by the pharmaceutical companies as we ever were. Academic physicians maintain that they need the money the drug industry provides for research because government funding has decreased. Yet these are the same doctors who write the practice guidelines. And it’s a given that the electronic health record is as much a compliance document as a medical chart—i.e., is every heart patient who should be taking a statin receiving a prescription? (If not, you may be paid less, or even incur legal liability for not adhering to the standard of practice if that patient has a heart attack.)

We want to trust the experts, just as our patients trust us. We don’t have time to follow the money ourselves. Yet experience has made us cynical. When the 2013 guidelines from the cardiologists greatly increased the number of patients eligible for statins, our skepticism broke into print, with editorials questioning whether, when age alone is the risk factor, statin therapy for primary prevention is warranted for everyone over age seventy. Some specialists responded that guidelines have to be black and white, that primary care doctors are not sophisticated enough to assess individuals in a gray area. Hell, we live in the gray area.

In retrospect, I tend to remember the arguments I had with patients who told me that I was too stingy with narcotics. But I, too, wrote many prescriptions. I will never know if I was stingy enough.

Toni Martin is a physician and writer who lives in Berkeley.

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