Fueling America’s Opioid Addiction

The system that sparked an epidemic—and keeps it going.

When Anna Lembke, MD ’95, first established her psychiatry practice at Stanford, she made one thing very clear: She would not see anyone who was addicted to drugs or alcohol.

“The way I was educated in medical school,” she says, “was not to think about addiction as an illness.” For much of the last 200 years, she says, the medical community (like the rest of society) has largely viewed addiction as a failure of either morals or willpower, and drugs as somehow distinct from medicine. According to her, that partly explains how doctors became complicit in the ongoing opioid epidemic, which the CDC first declared in 2011 after a decade-long increase in annual overdose deaths.

That’s one of the thrusts of her recent book, Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop, although Lembke is quick to point out that a few rogue doctors can’t be blamed for the uptick in prescription drug overdoses. When the CDC formally declared that the United States was facing an epidemic, “the main focus was on ‘pill mill’ doctors. I thought to myself, that’s an element, but that’s not what’s really going on. It’s everybody. That’s the only way we could get to this point where the U.S. prescribes [and] consumes 80 percent of the world’s opioids but is 5 percent of the population.”

In the book, she puts a human face on addiction with anecdotes from her own practice, which range from a high schooler whose addiction to pain pills began after she underwent emergency surgery to a 60-year-old recovering alcoholic who got hooked on morphine during treatment for a lower back infection. But Lembke also traces the history of how, as she says, Big Pharma came to be “in cahoots with organized medicine” — namely through pharma-sponsored conferences and pharma-backed medical societies that, among other things, falsely characterized opioids as a safe treatment for all types of pain, and without the risk of addiction. As a result of that lobbying, state medical boards and the Joint Commission created a 10-point pain scale and implemented patient satisfaction surveys. With insurance companies’ willingness to reimburse them for writing prescriptions, doctors are trapped between the desires of their patients and the pressures from their institutions, and financially incentivized to keep doling out high-powered pills.

Anna Lembke, MD (Photo: Courtesy Anna Lembke, MD)

This system, Lembke argues, reduces patients to customers and doctors to prescribers, and has quadrupled opioid prescription rates since 1999. And worse, with ongoing stigma and little support from insurance companies and the medical community writ large for addiction, the CDC now estimates that 91 people fatally overdose in America each day.

In light of the ongoing epidemic and public discussions about the future of health care in America, Stanford sat down with Lembke to discuss the book, the epidemic and how it all might get better. The conversation has been edited for clarity.

STANFORD: What motivated you to transition from running a purely psychiatric practice to treating addiction as well?

ANNA LEMBKE, MD: I had this patient that I was treating for depression — let’s just call her Cindy — and I was prescribing her one of the standard antidepressants. She would come into our sessions nodding off. I thought that this was like a case-reportable example of somebody with a super-sedation syndrome related to the antidepressant. I became very fascinated with this, like, “Yeah, maybe you have one of these enzyme mutations.”

One day out of the blue — I’ve been treating this woman for a year and she’s not getting better — and I get a call from her brother. He says, “Cindy was in a rollover car accident. Thankfully, she’s not hurt, but you know she could have died, she could have hurt other people. And she was using. . . . ”

And I’m like, “Using what?”

And he says, “Well, she was using heroin.”

“Heroin? She was using heroin?”

And there was this pause, and he says, “You are telling me that you, as her psychiatrist, don’t know that she is a heroin addict? She’s upstairs right now, with her rig.”

Now I didn’t know what a rig was, either; I had to look that up. That was the day . . . I felt that I had inadvertently harmed this patient. I was, like, the completely clueless psychiatrist.

STANFORD: What are the prospects for people like Cindy, if they can get treatment?

LEMBKE: Response rates to treatments for addiction are about 50 percent. That’s on par with the kinds of response rates we see for other chronic illnesses with a behavioral component, whether it’s type 2 diabetes — the behavioral component being diet — or it’s certain types of heart disease that are related to activity level. So, addiction behaves very similarly in terms of rates of remission, compliance with treatment and rates of recurrence, or what we call relapse in the addiction world. What that tells you is that it really acts a whole lot like other chronic illnesses; hence, it should be treated like a chronic illness.

STANFORD: Before they try “street drugs” like heroin, many addicts first get hooked on opioids from a prescription. As you describe in your book, sometimes that’s after a surgery, but sometimes it’s after a more mysterious diagnosis of pain, without a clear pathology. At the risk of sounding insensitive, is that pain “real”?

LEMBKE: There are people out there who have devastating pain syndromes that we don’t fully understand, that wreak havoc on their lives. I have a great deal of empathy for those people. What I’m talking about is a little bit new and separate from that: increasing numbers of young, otherwise healthy people, coming in with inexplicable pain syndromes. So there’s no injury or observable disease that we can find anywhere in their bodies. And yet they have intense pain in various regions of their bodies, or even all over their bodies.

It’s pain for them. But I think what has happened is ultimately psychological distress being somatized — it unconsciously manifests as a physical pain. This phenomenon has happened across cultures through millennia, the somatization of psychiatric disorders.

What’s different today is when you sign up for the patient role and show up in a doctor’s office, there’s a very high chance you’re going to walk away with a prescription for an incredibly potent, potentially addictive medication. The risk to you is huge.

STANFORD: Given that risk, should doctors stop prescribing opioids altogether?

LEMBKE: I don’t think we should completely shut off the faucet. I think for people who do become addicted, we should open the faucet to opioid addiction treatment, and we haven’t done that well either.

If opioids really helped people when taken at high dosages for long periods, I would have no problem prescribing them. It’s not like I’m morally opposed to opioids. It’s that over time they end up harming people, and they actually stop helping for the pain.

STANFORD: Despite how complicated the problem is, you end the book on a somewhat hopeful note. What might “better” actually look like?

LEMBKE: What I would love to see are patient-consumers who are much more wary in their consumption of medical products. If you look at groups, who are wary consumers of medicine? Christian scientists and doctors. Doctors consume a great deal less medical treatment than most people.

Medicine can do a lot of wonderful things — it’s expanded the life span from three decades to now almost eight in high-income countries. It’s relieved a lot of suffering and saved a lot of lives. But it also is doing a lot of damage. And we need to communicate that.

The problem is that because medicine has become business, you’re not going to find people holding back on delivering medicine or medical care that makes them and their institution a lot of money. That’s not going to happen. It has to come from the consumers, who have to shift their thinking about the benefits of engaging and consuming certain types of medical care. Ultimately, that’s my goal. •