Anna Lembke

Dr. Lembke isn't the first health care practitioner to feel like a drug dealer (I'd love a dollar for every time I've said it), but she is one of the only ones to write a comprehensive overview of the relationship between prescribers, patients and pain pills. Drug addiction has been a hot topic in America for the last hundred years or so, but it's ramped up in the past twenty as opioid addiction has hit more people close to home. I'm not particularly fascinated by the topic, but it is unavoidable in hospital medicine. After reading [b:Dopesick: Dealers, Doctors, and the Drug Company that Addicted America|37486540|Dopesick Dealers, Doctors, and the Drug Company that Addicted America|Beth Macy|https://i.gr-assets.com/images/S/compressed.photo.goodreads.com/books/1533010748l/37486540._SY75_.jpg|59097428], a Lifetime Movie of the Week masquerading as journalism, this book was recommended. I can see why, because it's everything Dopesick isn't: organized, largely factual, and comprehensive. If you want to understand the mechanisms behind the Modern Pain Factory, this will certainly help.

There are ten chapters: What is Addiction, Prescription Drugs as the New Gateway, Pain Is Dangerous, Big Pharma Joins Big Medicine, The Drug-Seeking Patient, The Professional Patient, The Compassionate Doctor, the Narcissistic Injury, Pill Mills, Addiction-the Disease Insurance Companies...Won't Treat, and Stopping the Cycle (abridged titles). Despite the broad overview, it's only about 150 pages, not counting references, so it doesn't feel as overwhelming as it could. In fact, according to my ScienceBrain, for the most part it is written extremely well, with each sentence providing information or an interpretive punch. I literally had highlights on over half the pages I read.

As a nurse who practiced in inpatient oncology from 2003 to 2020, I have to tell you that I witnessed almost everything she is describing, from the influence of drug companies on doctors ("Eat this steak dinner while we give you a presentation on our drug, XZD"), to patient care surveys ("Did the staff do everything they could to treat your pain?"), to teaching seminars on "Pain as the Fifth Vital Sign" (I proudly held the title of "Pain Resource Nurse" after one of them).

The writing is crystal-clear, and no one is spared: "The prescription drug epidemic is first and foremost an epidemic of overprescribing... today the extent to which doctors rely on prescription drugs, especially scheduled drugs, to treat their patients for even routine, non-life-threatening medical conditions is unprecedented." She notes that in the 1980s, prescribing patterns began to liberalize, speculating that it was because of an aging population, more people living after complicated illnesses and procedures, and the growth of the hospice movement. But I laud her for this summary: "But to ascribe all the blame to Big Pharma is to oversimplify. The pharmaceutical industry was able to influence doctor-prescribing only by joining together with academic physicians, professional medical societies, regulatory agencies (the Federation of State Medical Boards and The Joint Commission), and the FDA."

It's hard for the non-medical person to understand, but Lembke does a nice job of laying out how all of those entities moved doctors to a point where they felt scheduled drugs were 'just another tool in the toolbox' (a very common descriptive term in pain management education). What I was hoping for is how some people are also their own drivers for pain. She talks a little bit about addiction, and how both nature--the genetics of addiction--and nurture--children raised in families with substance use, with trauma, conflict and availability all increasing risk--can increase likelihood of addiction. But chronic pain and addiction are more closely linked than we've been willing to admit, and that's the part that is challenging to tangle out. After seeing a number of cancer patients in intense pain despite massive doses of narcotics--and I'm talking both habituated dosing and needing doses to the point of insensibility--I've been leaning into the idea of emotional/spiritual and even social pain, and I don't think we can legitimately solve the addiction issue until we understand the complex phenomenon of chronic pain.

Personal blah blah: Clearly, I've spent half my professional life with cancer patients, which often means narcotics as disease advances or with surgical fallout. But the relationship to pain medicines also seems to bear a relationship with how the patient deals with their disease. Particularly with older people ("The Greatest Generation"), I've found myself teaching how narcotics can be life-improving. The emotional burden of pain and the inhibiting effect of pain on daily life --eating, walking--means controlling it is critical, and sometimes narcotics just seem to do it best and reliably. But they often dislike narcotics, perhaps because of stigma, but also perhaps because it signifies that the cancer is 'winning' to them. Yet I've seen others embrace the idea of pain medicines, and even with a generally non-physiologic painful condition, they turn to narcotics easily. What's behind that? Untreated chronic pain? Coping mechanisms? This is the intersection that I'm fascinated by, and that medicine needs to address.

Since this book was published in 2016 (!), there's been a huge pulling back in prescribers writing scheduled drugs, much to the dismay of many patients. She notes in one section how at the heyday in 2012, 650 million oxycodone were prescribed, enough oxycodone to give every resident 34 pills. After crackdown on the "Pill Mills," it dropped to 313 million in 2013. I fact checked this one for an update, and wow, it's amazing. The CDC reports in 2012, 255 million opioid prescriptions were written in the U.S. Despite population growth, in 2019, it's down to 153 million. (Hint: if you want prescription drugs, go to Alabama). The big unanswered question is what did we accomplish? Decreasing addiction or reducing medicine's role in the phenomena? As I think we've discovered, the overdose rates are just going up as people turn to street drugs instead. Lembke talks a little bit about this path of prescription to illegal drugs, as pill mills dry up while addicts need their fix. However, if you look at prescriptions as the 'gateway' to opening up an addictive path--and Lembke surely does--we have hopefully reduced the addiction risk for the next generation.

As a psychologist, she also touches on the 'types' of patients she sees seeking scheduled drugs, and some of their techniques. I was most wary of this section, which is more broad categories of behavior more than DSM type criteria. She does note the busy crossroads of mental health conditions and addiction as well. I found her examination of the 'professional patient' phenomena intriguing, the idea of an illness diagnosis as both a profession and a way of thinking. I have to say that I've seen what she's talking about. I did appreciate that she touched on disability payments and such as part of the issue--not to say that patients are faking anything, but that the system we have in place dis-incentives people for improving their health and increasing self- management. It was one of those 'ah-ha' moments that made me think of the Universal Basic Income movement and the potential impact it could have.

My other enlightening moment was in her discussion of insurance and addiction. I had read before that only 50% of addicts who go through intensive treatment are successful at staying off drugs for a year, and considered that a dismal success rate for treatment. But if we re-conceptualize addiction as a 'chronic illness,' and treated it with the same resources we treat other chronic illnesses, we could make a dramatic change in many lives. For instance, we invest in years of three-times-weekly dialysis treatments despite no hope of reversing the condition. Likewise, if we stopped blaming addicts and started treating them anyway, noting that we treat other biologically-inclined but self-influenced medical conditions like Type II diabetics. She lays out several possible paths at the end for reform, mostly dealing in the medical reimbursement model, parity, and more education of medical staff. There may have been more details, but they didn't stick, because they are largely not going to happen.

This is a comprehensive overview done relatively quickly, with examples through a couple of detailed case studies to bring the human element. I finished, but felt like a few sections were lacking, particularly in the psychology of the patient, and in the neurological aspects of addiction. But when I flipped back through pages, I realized she did cover those topics in the same broader strokes as others--it's just that I was hoping for something even more detailed. My analysis is that if you want a really in-depth look at a particular aspect of prescriptions and addiction, you will be slightly disappointed and should head towards a text with a narrower focus. But if you want to understand how we got to the prescription drug crisis, this is the book.

Post-script:

It rarely makes the news anymore, but the government is continuing to investigate and prosecute those who were involved in the prescription drug crisis, although they are more than a few years behind. Just as I was wrapping up this book, details were breaking on the Sackler family and Perdue Pharma, and their lawsuit losses against multiple states. Then my medical newsletter provided me with yet another update: five doctors charged, four sentenced, for their role in accepting bribes and kickbacks for prescribing Subsys, spray Fentanyl, in 2012, and the manufacturer of it, Insys, sentenced for his role in the 2012 epidemic.

As always, you'll have better luck with links at my blog. https://clsiewert.wordpress.com/2021/07/14/drug-dealer-md-by-anna-lembke-md/… (more)

An interesting book on addiction.

There is a pleasure pain balance. Pleasure is balanced by pain. More pleasure leads to more pain in order to maintain the balance.
Here is a trivial example: The pleasure of chocolate, the pain of longing for more.

Here is a quick summary of possible strategies.

Chapter 4 Dopamine Fasting
DOPAMINE
- D - Data
- O - Objectives
- P - Problems
- A - Abstinence
- M - Mindfulness
- I - Insight
- N - Next Steps
- E - Experiment

Chapter 5:
Self-Binding
- Physical
- Chronological
- Categorical

Chapter 6: A Broken Balance
- Meditation to restore a level balance

Part 3: The Pursuit of Pain

Chapter 7 Pressing on the Pain Side
- Cold water immersion
- Exercise - “Exercise is immediately toxic to cells,”
- Pain to treat pain (including Acupuncture)
- Doing something hard (like talking to strangers)
- Addicted to pain (rat running wheel, extreme sports)
- Addicted to work
“If we consume too much pain, or in too potent a form, we run the risk of compulsive, destructive overconsumption.”
“But if we consume just the right amount, “inhibiting great pain with little pain,” we discover the path to hormetic healing, and maybe even the occasional “fit of joy.””

Chapter 8 Radical Honesty

“The average adult tells between 0.59 and 1.56 lies daily. Liar, liar, pants on fire.”

“Radical honesty—telling the truth about things large and small, especially when doing so exposes our foibles and entails consequences—is essential not just to recovery from addiction but for all of us trying to live a more balanced life in our reward-saturated ecosystem. It works on many levels.“

Section: Honesty Promotes Intimate Human Connections

“Intimacy is its own source of dopamine.”
“Any behavior that leads to an increase in dopamine has the potential to be exploited. What I’m referring to is a kind of “disclosure porn”…”

“In more than twenty years as a psychiatrist listening to tens of thousands of patient stories, I have become convinced that the way we tell our personal stories is a marker and predictor of mental health. “
“Patients who tell stories in which they are frequently the victim, seldom bearing responsibility for bad outcomes, are often unwell and remain unwell. They are too busy blaming others to get down to the business of their own recovery. By contrast, when my patients start telling stories that accurately portray their responsibility, I know they’re getting better.”

Section: Truth telling is contagious and so is lying

“Truth-telling engenders a plenty mindset. Lying engenders a scarcity mindset.”

Chapter 9 Prosocial Shame

“The thinking goes like this: Shame makes us feel bad about ourselves as people, whereas guilt makes us feel bad about our actions while preserving a positive sense of self. Shame is a maladaptive emotion.”
“Guilt is an adaptive emotion. My problem with the shame-guilt dichotomy is that experientially, shame and guilt are identical.”

“Yet the shame-guilt dichotomy is tapping into something real. I believe the difference is not how we experience the emotion, but how others respond to our transgression.”… (more)