Shall We Dance—New Book Describes Complex, Psychological Tango Between Physician and Patient Over Opioid Prescriptions

Jane and I are seven days into a 10-day cruise to (and from) the Panama Canal. I’m gloating, of course. While even our native Durham, North Carolina, is currently shivering, we’re basking in hot, sunny weather “down here.” Knowing that cruise ship Internet is expensive, I determined to do some old-fashioned reading on the Promenade deck this week, so I tossed a relatively new title into my suitcase just before departure. I’m so glad I did. Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop, by Anna Lembke, M.D. [Johns Hopkins University Press, ISBN–13: 978–1421421407 (September 28, 2016)], should be on every workers’ compensation practitioner’s “Santa’s list” this Christmas.

Title is Somewhat Deceiving

In some respects, Lembke’s title is a bit deceiving, since it signals that most of the blame for the opioid epidemic lies at the feet of physicians. While Lembke isn’t bashful when it comes to pointing her finger at colleagues—Lembke is chief of addiction medicine at Stanford University Medical School—she stresses America’s opioid addiction explosion actually springs from three separate factors:

• Exaggerated estimates by Big Pharma as to the number of Americans with chronic pain, coupled with a massive marketing campaign promoting the use of opioids and other prescription pain killers—Lembke says the pharmaceutical companies have estimated 100 million sufferers, while she claims the correct number is one-quarter of that figure.
• Too many doctors prescribing long-acting, high-dose narcotics to treat toothaches and minor injuries, when the drugs are primarily meant to relieve cancer pain and other severe, unremitting conditions. Lembke joins others in warning that the more opiates in circulation, the greater the opportunity for patients—and non-patients—to abuse them.
• As Lembke observes from her own practice, many patients “visit a doctor’s office not to recover from illness, but to be validated in their identity as a person with an illness.”

Origins of the Problem Stem from the 90s

As do a number of other medical experts, Lembke traces the origins of the opioid addition problem to the 1990s, when campaigns for improved pain treatment gained ground. She reiterates that in 2001, responding to what was thought to be widespread under-treatment of pain in the country, the Joint Commission on Accreditation of Healthcare Organizations established standards for pain management. Lembke acknowledges that at the time, inadequate treatment of pain was a problem. By the second decade of the 21st Century, however, the pendulum had swung too far in the other direction.

Problem Tied to the Way Medicine is Typically Practiced

Examining her own practice and the practice patterns of her colleagues, Lembke allows that one important factor in the rise of opioid abuse has to do with a common problem: doctors are too busy. She adds that a physician often has a dilemma: does she take the time required to discuss the possibility that the patient is misusing painkillers, knowing all along that such a discussion will wreak havoc with that day’s schedule, or does she postpone the issue by reaching for the prescription pad? The physician is generally paid according to the number of patients she sees in a day. “Hurry, hurry,” is the rule of the day. Haste leads to problems, says Lembke.

Lembke adds that those doctors that do try to wean patients from narcotics can sometimes face another difficulty—an insurance company that doesn’t want to provide benefits for anti-addiction medications, such as buprenorphine (an opiate replacement drug). According to Lembke, some doctors just avoid the hassle, feeling that too much time gets spent negotiating with the carrier.

Patients Gaming the System

I found Lembke’s description of patients that are adept at gaming the system to be particularly humorous—and incisive. Dr. Lembke explains that all too many patients fall into three common categories. Lembke labels one type “senators,” since their style is to “filibuster” the doctor with unrelated questions and issues until the very end of the office visit, only then plea for narcotics. Short of time, knowing she has a lobby full of other patients, the doctor relents. Less effective, but still numerous are “Exhibitionists”—patients who writhe around in fake pain. Lembke added that often the doctor is tag-teamed by “Dynamic Duo’”’—a patient and his or her crying mother (whom Lembke labels “the commonest co-dependent”). Lembke adds that for many physicians, this duo presents a situation too pitiful to refuse.

The Dreaded “Patient Satisfaction Survey”

Why don’t more physicians stand up to these sorts of patients? Lembke allows that many doctors would show more backbone if it weren’t for patient satisfaction surveys. Indeed, it isn’t just medicine—our consumer society has gone customer survey mad and the phenomenon exacerbates the opioid abuse problem. Lembke reminds us that those who get poor satisfaction scores face potential difficulty with Medicare and Medicaid. Dr. Lembke admits that she has sometimes found herself between the rock and a hard place—should she risk the patient’s ire and refuse the requested prescription, or “satisfy” the patient and avoid a negative review. Lembke argues that under America’s current system, the incentive is to prescribe opioids even when the doctor thinks it is not in the patient’s best interest.

Psychology of Medical Practice

I found Lembke’s argument about physician psychology to be well reasoned and fascinating. She notes that, contrary to somewhat popular belief, doctors are people, just like the rest of us. Most have a sincere desire to maintain mutually affectionate relationships with patients—to be thought of as a beneficial shaman (my word, not hers). Doctors want to alleviate suffering. Lembke posits that where the doctor denies a patient his or her usual opioid dose, the “therapeutic alliance” itself can be threatened. And yet, in the doctor’s heart and mind, he or she also recognizes that to continue to prescribe opioids to a patient who is misusing them is to engage in de facto drug dealing, which also threatens a doctor’s identity. The physician is often adrift within this Twilight Zone.

Lembke’s Book Gets Mixed Reviews From Others

I was surprised that the book has received mixed reviews. While virtually all the reviews I found were generally positive, several found fault with the paucity of Lembke’s study data. They would like to see much more hard data to back up some of Lembke’s proposals and opinions. For example, it’s true that the average opioid abuser often doesn’t fit Lembke’s “patient” model. Many in the workers’ compensation community, for example, argue that the typical abuser is not a pain patient at all, but rather a non-patient who gets the medication from unsuspecting relatives, purchases it on the street, or finds a pliable pain pill mill—someone operating as a “pain” specialist.

My Own Conclusion: Well Written, Informative Ethnography

I found Lembke’s book to be a refreshing change from the usual dry, statistical study that must be read and reread in order to glean the actual findings. In many respects, Lembke offers a potent and poignant ethnography of life in the trenches, or rather, life on the dance floor, as the patient and physician continue their uneasy tango. Lembke gives those of us without bad backs or medical degrees a candid, sharp, and caring commentary on what it means to be a pain patient, what it’s like to be a physician trying to deliver quality medical care under tight schedules and bureaucratic regulations, and how the current medical models are coming apart at their seams.