Pharmacy retail sales of opioid painkillers, obtained through doctors’ prescriptions, quadrupled between 1999 and 2010, and accidental opioid overdoses are now the #1 cause of injury death in the U.S.—exceeding deaths due to motor vehicle accidents. This scourge is affecting people of all races, places, and walks of life. And this epidemic is showing no signs of slowing down.
Anna Lembke, MD, is Assistant Professor and Chief of Addiction Medicine at the Stanford University School of Medicine. Dr. Lembke recently published the book Drug Dealer, M.D.: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop. She answered questions about opioid overprescribing, signs of addiction, and what can be done to stop our country's addiction epidemic.
Most of us are at least somewhat familiar with alcoholism and “street drug” addiction, but addiction to prescribed drugs, and opioids in particular, seems a much newer epidemic. When and why did this problem suddenly become so much larger?
The current prescription drug epidemic is first and foremost an epidemic of overprescribing, not just of opioid painkillers, but of other controlled medications such as sedatives (Xanax) and stimulants (Ritalin).
Doctors began prescribing more opioids in the 1980s out of compassion for those people living with intolerable pain. But what began as an act of compassion quickly turned into inadvertent harm, and eventually a blatant disregard of patients’ well-being, as doctors got caught up in a system gone awry. My book looks at the unseen forces driving the epidemic as a way to get at the root of the problem and find ways to solve it. I am particularly interested in the average compassionate doctor (rather than the willfully nefarious one) who went into medicine to save lives and ease suffering, then found himself/herself acting against intuition and better judgment when prescribing potentially dangerous drugs.
What factors caused this rapid and relatively recent rise in the number of opioid pills prescribed by doctors?
The factors driving overprescribing are many and complex; here are some of the most important:
Interwoven through all of this is the complex interpersonal dynamic between doctors and patients—riddled with mutual deception, wishful thinking, wounded pride, and desperate attempts on both sides to pretend that a doctor’s only mission is to heal and a patient’s only mission to recover from illness.
Even when addiction is recognized by doctors and their patients, doctors don’t know how to treat it; no infrastructure exists to provide that treatment, and insurance companies won’t pay for it.
What has changed in medicine that is driving physicians to prescribe so much more than was once the case?
The biggest change in medicine, which has contributed significantly to the prescription drug epidemic, has been the mass exodus of physicians out of physician-owned practices and into integrated health care institutions. Prior to 2000, the majority of doctors worked in physician-owned practices. Today, the majority of doctors are salaried employees in large health-care conglomerates, with billing quotas, patient satisfaction surveys, and hospital “quality measures” driving them to provide a certain kind of care — even when that care is against their better judgment and/or the health of the patient. To be sure, top-down medicine has the potential to improve many aspects of medical care, and probably allows more people access to medical care; but when it comes to prescribing pills as a short-term quick fix for complex problems, top-down medicine has been a disaster.
In addition, pain has “become its own disease” — a relatively recent change in medical perspective. While this phenomenon has resulted in better treatment for some, another outcome has been a startling rise in the prescribing of opioids.
Can you explain further how this “disease-ification of pain” may have contributed to overprescribing of opioids?
Prior to 1900, pain was viewed as an immediate and short-lived response to an injury or illness — the body’s emergency warning system that burned bright and then burned out. Once the injury healed or the illness was cured, (or the body just got used to it, whichever came first), the pain — so the thinking went — disappeared. There was no framework or lexicon for chronic pain, especially in the absence of injury or objectively verifiable disease.
Today, hospitals and clinics are overrun with patients struggling with a growing variety of chronic pain conditions. Indeed, the number one cause of Social Security Insurance (SSI) disability today is chronic pain. Compare this with the 1980s, when the leading causes of disability were heart disease and cancer. Furthermore, pain today need not be caused by an injury or illness. Pain can be its own disease. A growing list of chronic pain conditions has emerged for which there is limited understanding and no obvious medical antecedent: fibromyalgia, complex regional pain syndrome, pelvic pain syndrome, etc.
Another aspect of pain management that has changed in the last 150 years is the approach to peri-operative pain. As recently as the mid to late 1800s, pain during surgery was considered salutary by boosting cardiovascular and immune function and thereby expediting healing. By the 1950s, with advances in anesthesia (methods of rendering patients unconscious) and analgesia (methods of eliminating acute pain) — especially the growing availability of synthetic and semisynthetic opioids — pain during surgery was no longer associated with any beneficial medical effects. (Of interest, recent reports have shown that patients who receive opioid painkillers during surgery have slowed rates of tissue healing compared to those undergoing the same surgery without opioids, which may be attributable to opioid suppression of the immune system.)
A third way medicine’s conception of pain has changed over time: today, pain is “bad” — not merely because it is painful, but also because it is believed to engender future pain by leaving a neurological scar, so to speak. Such conditions are of late referred to as “centralized pain syndromes,” and localize the source of the pain in the brain, rather than out in the body. As a psychiatrist, I can’t help but note the parallels between centralized pain syndromes and post-traumatic stress disorder, both of which link the acute experience of pain as a potential source of long-lasting pain.
Over the course of the past century, these changes in the way medicine and society view pain have allowed for a lessening of the burden of suffering for many people with pain; however, this altered perspective has also inadvertently contributed to the opioid epidemic by encouraging doctors to overprescribe opioids for chronic pain as a way to make the elimination of all pain the goal of medical treatment. Emerging evidence suggests that opioids are not effective when used long-term for pain (they are very effective for short-term, i.e., 1-3-day, pain). Opioids may even cause serious adverse health consequences, including making pain worse when used for more than a month and impeding the healing process.
What role has “Big Pharma” played in the rising prescription levels?
Big Pharma (a nickname for the multi-billion-dollar pharmaceutical industry) has always been in the business of getting doctors to prescribe more drugs, and they have used every tactic at their disposal to do that. What changed in the last 30 years was that Big Pharma infiltrated Big Medicine (The Joint Commission, The Federation of State Medical Boards, the Food and Drug Administration) in an unprecedented way, to convince doctors that prescribing more opioids was not what Big Pharma wanted, but rather what science supported. Turns out none of it was true. There is no evidence that opioids are effective in the treatment of chronic pain when used long term. (Opioids are very effective when used short-term for acute pain.) Doctors, increasingly pressured to practice so-called “evidence-based medicine,” prescribed more opioids for chronic pain because they were misled to believe medical science supported it. It also happened to be a convenient solution to the increasing industrialization of medicine, in which some doctors are forced to see upwards of 40 patients a day.
What can stop the overprescribing of drugs in the U.S.?
Unfortunately, the prescription drug epidemic is likely to continue for the foreseeable future — unless we do more to target the unseen forces driving the epidemic. (However, even public discussion of these unseen forces verges on political incorrectness.)
What it will take to stop the overprescribing of opioids, and other pills, is a restructuring of medicine to a system which reimburses doctors to provide the kind of treatment that actually helps pain in the long term. Beneficial treatments include behavioral and psychological interventions ranging from psychotherapy to physical therapy and everything in between — not pills.
Can we hope that clinical research studies will indicate or prove how detrimental chronic opioid use is for so many, even relative to the pain management benefits they may provide for some?
There are already many studies showing the damage that exposure to chronic opioids can cause — including increased risk of fractures, disordered breathing, and delayed tissue healing, to name a few. Ironically, chronic opioids can also cause increased pain over time, a condition called opioid-induced hyperalgesia. And let’s not forget of course the risk of addiction, as well as the risk of accidental overdose.
Are there other drugs physicians are starting to prescribe too much… and that may prove more addicting than first thought? In other words, is there another Rx epidemic in the offing?
Prescriptions for stimulants to treat attention deficit disorders, especially among ever-younger children, some as young as 2 years old, have sky-rocketed in the last few decades, along with prescriptions for sedatives and anti-anxiety medications. Because these medications are less likely to cause overdose and accidental death, we hear less about them, but my clinical practice is full of people addicted to these prescription drugs, most of whom got started on those drugs by a doctor.
Can you explain why some individuals may be “dependent” on a substance, including opioids, whereas others are more than just dependent, but rather are “addicted”?
The great and enduring mystery in the field of addiction is why some people can use addictive substances in moderation and never get hooked, while others eventually progress to addictive behavior. The risk is some combination of nature, nurture, and neighborhood. The risk of developing addiction increases 4-fold if the individual has a biological parent or grandparent with addiction. Mental illness and early trauma increase the risk of addiction. Growing up in an environment in which maladaptive substance use is modeled and condoned is also a risk factor. Perhaps the greatest risk factor of all is simple access: if alcohol and drugs are readily available, the individual is at greater risk to use them and become addicted to them.
How can a family member or friend tell if a loved one might be addicted to opioids or other drugs… and if it becomes evident that there is a problem, what’s the best approach for dealing with it and getting help?
Signs of addiction include lying, blaming, erratic behavior, and poor function at work, school, home. I always tell parents that if your kid is not doing well, and spends a lot of time unaccounted for, or has had an abrupt change in personality, think drugs. This is one instance in which being a helicopter parent is a good thing: search their back-packs, their rooms, their phones. Find out where they’re going, what they’re doing, who they’re with. Respecting autonomy is well and good, but if you’ve got a teenager in trouble, dive in and try to find out what is going on. If you find out alcohol and/or drugs are involved, find the resources in your area that help people with drug and alcohol problems.
Tell us what one can expect about addiction recovery success rates. Is the forecast rosy or dim? Improving?
It’s a myth that people with addiction don’t get better. About 50% of people who get addiction treatment get into recovery, response rates that are on par with those who get depression treatment. Many recover without any professional treatment at all. Those who actively participate in AA and other 12-step groups have outcomes on par with those who get professionally mediated treatment, like cognitive behavioral therapy. AA may even be better than CBT long-term, for those who have a goal of abstinence.
… any final thoughts?
Above all, be a wary consumer of prescription drugs. Even your doctor may not realize a drug he/she is prescribing has the potential for addiction.