Drug Dealer, MD

DRUG
DEALER,
MD
How Doctors Were Duped,
Patients Got Hooked,
and Why It’s So Hard to Stop

ANNA LEMBKE, MD
© 2016 Johns Hopkins University Press
All rights reserved. Published 2016
Printed in the United States of America on acid-free paper
987654321

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Library of Congress Cataloging-in-Publication Data

Names: Lembke, Anna, 1967–

Title: Drug dealer, MD : how doctors were duped, patients got hooked, and
why it’s so hard to stop / Anna Lembke, MD.
Description: Baltimore : Johns Hopkins University Press, 2016. | Includes
bibliographical references and index.
Identifiers: LCCN 2016010031 | ISBN 9781421421407 (pbk. : alk. paper) |
ISBN 1421421402 (pbk. : alk. paper) | ISBN 9781421421414
(electronic) | ISBN 1421421410 (electronic)
Subjects: LCSH: Analgesics. | Medication abuse. | Physician and patient. |
Drugs—Prescribing. | Drug addiction.
Classification: LCC RM319 .L46 2016 | DDC 615.7/83—dc23
LC record available at http://lccn.loc.gov/2016010031

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To every patient who has been addicted to prescription
drugs, to their loved ones, and to all the doctors who went
into medicine to do good but feel trapped by a system gone
awry
 Contents

Acknowledgments
Note on Terminology

Prologue
1 What Is Addiction, Who’s at Risk, and How Do People Recover?
2 Prescription Drugs as the New Gateway to Addiction
3 Pain Is Dangerous, Difference Is Psychopathology: The Role of Illness
Narratives
4 Big Pharma Joins Big Medicine: Co-opting Medical Science to
Promote Pill-Taking
5 The Drug-Seeking Patient: Malingering versus the Hijacked Brain
6 The Professional Patient: Illness as Identity and a Right to Be
Compensated
7 The Compassionate Doctor, the Narcissistic Injury, and the Primitive
Defense
8 Pill Mills and the Toyota-ization of Medicine
9 Addiction, the Disease Insurance Companies Still Won’t Pay Doctors
to Treat
10 Stopping the Cycle of Compulsive Prescribing

References
Index
 Acknowledgments

This book would not have been possible without my patients’ willingness to
share their stories. I thank them for their generosity and courage. I also
thank the many health care professionals who agreed to be interviewed;
their experiences and perspectives lend richness and texture to my own.
I’ve had many wonderful teachers over the years. I am especially
grateful to Keith Humphreys and John Ruark, who have guided me,
challenged me, and always rooted for me.
Several people have read all or parts of the manuscript along the way.
My thanks to my editors Robin W. Coleman and Barbara Lamb and to
several anonymous reviewers for Johns Hopkins University Press. Special
thanks to my mother-in-law, Jean Chu, one of my earliest readers, a
fantastic editor, and a dear friend.
My deepest gratitude to my husband and children, for allowing me time
and relative quiet to work on “the book.”
 Note on Terminology

The terminology to refer to people who use drugs and become addicted to
drugs is in flux. There is increased awareness, especially among treatment
providers, that the language currently used to describe addiction stigmatizes
the people involved. Examples include calling someone who is in recovery
“clean,” as if they were “dirty” before; referring to addictive drug use as
“drug abuse,” which conjures images of other forms of abuse, such as child
abuse; or referring to the addicted individual as a “drunk” or a “junkie.”
Throughout this book, I have attempted to avoid stigmatizing language
in favor of more neutral terms, such as “use,” “misuse,” “overuse”
“addictive use,” and “addiction.” Nonetheless, terms like “addict,” “drunk,”
and “junkie” do appear in this book, when patients themselves use these
words to describe their behavior and experiences. Indeed, in the twelve-step
self-help community (Alcoholics Anonymous, Narcotics Anonymous, etc.),
members often refer to themselves as “alcoholic drug addicts.” My use of
these terms is hence not meant to be pejorative, but to capture the language
and experience of drug-addicted individuals.
Drug Dealer, MD
 Prologue

After I finished medical school in 1995, followed by a residency in

psychiatry and a fellowship in mood disorders (an apprenticeship period
that follows medical school), I was finally ready, after nearly ten years of
medical training, to treat patients on my own. As I was establishing my
clinic at the academic medical center that hired me, I informed the intake
coordinators (who check insurance, do a brief psychiatric assessment by
phone, and triage patients to the appropriate clinic) that I wouldn’t see
anyone addicted to drugs or alcohol.
My reluctance in those days to treat patients with substance* use issues
was consistent with my training. I received no education in medical school
on the treatment of addiction, and limited education on addiction even
during my residency in psychiatry. I was schooled to believe that addiction
is not a medical disorder and, therefore, not treatable in the traditional
sense. My teachers never mentioned existing pharmacotherapy and
behavioral interventions for substance use disorders. I acquired no skills on
how to talk with patients about the often thorny issue of harmful substance
use. Alcoholics Anonymous was mentioned, but outside of being
encouraged to observe an AA meeting as a guest, no education was
provided on how AA might be helpful to patients.
I soon discovered that, despite my effort to avoid treating patients with
substance use problems, many of my patients were either misusing or
addicted to a variety of substances. According to national surveys, 75
percent or more of patients with mental illness struggle with drug and/or
alcohol problems.1 I became aware of my patients’ substance use not
through any clinical prowess or discernment of my own. To the contrary, in
the 1990s I seldom if ever asked my patients about drug or alcohol use.
Instead, I typically came into this knowledge after a desperate call from the
patient’s family member, along the lines of: “Holly has been in a rollover
car accident. Didn’t you know that she shoots up heroin every day?!” No, I
was forced to admit, despite being her psychiatrist, I really hadn’t known—
mostly because I hadn’t thought to ask.
By the late 1990s, I realized I had one of two choices: I could continue
to ignore my patients’ substance use problems or I could figure out how to
target and treat addiction. Out of necessity I chose the latter. It became
increasingly clear to me that my patients were not going to get better
otherwise. Then began a period of reeducation for me. For the next ten
years, with the guidance of wonderful colleagues already versed in
addiction treatment, and the insight, and sometimes lack of insight, of my
patients—who proved to be the best teachers of all—I learned what
addiction is, how to detect it, and how to intervene to help patients
struggling with it. By default, I became the go-to person in my department
for patients with substance use disorders. In addition to alcohol, tobacco,
and marijuana, I saw increasing numbers of patients addicted to prescription
drugs.
The majority of my patients who were misusing prescription drugs were
not getting their drugs from a drug dealer; they were getting them from a
doctor. Sometimes I was the unwitting prescriber. The extent of the problem
was brought home to me in 2011, when I was asked to see a patient
admitted to the hospital for severe low back pain. My colleagues consulted
me to determine whether the patient was addicted to opioids.*
According to this patient’s medical records, her history was marked by
the classic downward spiral of a drug-ravaged life, including loss of jobs,
friends, family, and a recent near-death opioid overdose. In the months prior
to admission, she had obtained and presumably taken more than 1,200
different opioid pills obtained from sixteen different doctors.
I went to see the patient. I heard her before I met her, her demands for
more painkillers ricocheting off the walls of the hospital hallway. Her
nurses hovered outside her door, afraid to enter, a look of panic in their
eyes. When I walked in, the patient saw my white coat and seemed relieved.
She launched into her story of unbearable pain. She also freely admitted
being addicted to opioids in any form, from prescription painkillers to
intravenous heroin. But to her this presented no obstacle to obtaining more
pain medication: “I know I’m addicted, Doc, but if you don’t give me the
pills I want, I’ll sue you for leaving me in pain.”
 I realized then that we—I and my fellow health care providers—had
become trapped in a system gone mad. We were unable to deny this
obviously addicted patient more opioid painkillers, even when we were well
aware of the harm these medications were causing her. I recommended to
my colleagues that they slowly discontinue her opioid painkillers and refer
her to addiction treatment. None of my recommendations were followed,
and high-dose opioid painkillers were continued for the length of her
hospital stay. When she presented to the hospital again a month later, with
the same complaint of pain, she received the same treatment. All of us were
caught on a merry-go-round that we felt helpless to stop.

A Prescription Drug Epidemic

This patient’s care was not an aberration. Her case was emblematic of a
new normal. On November 1, 2011, the Centers for Disease Control and
Prevention (CDC), the agency of the government responsible for protecting
Americans from major health threats, declared a “prescription drug
epidemic”; and the CDC was unequivocal about what had caused this
epidemic: “prescription opioid painkillers and psychotherapeutic drugs
being prescribed more widely by physicians.”2 In the United States,
approximately 4,000 deaths involving opioid painkillers were documented
in 1999,3 increasing to 16,235 in 2013,4 quadrupling in little more than a
decade. The combination of opioid painkillers and sedative benzodiazepines
(for example, Valium) has contributed to a large number of the overdose
deaths.5, 6
Pharmacy retail sales of opioid painkillers, obtained through doctors’
prescriptions, quadrupled between 1999 and 2010,7 coinciding with a
quadrupling in prescription-opioid-related deaths. Prescribers wrote enough
opioid painkiller prescriptions in 2012 to medicate every American adult
around the clock for a month. Equally alarming has been the increased
prescribing of stimulants (for example, Adderall) and sedatives (for
example, Xanax) over the last three decades.
By 2010, for the first time in history, unintentional drug poisonings
represented the leading cause of injury death in the United States,
exceeding deaths due to motor vehicle accidents.7 The total toll of
prescription opioid overdoses between 1999 and 2013 exceeded 175,000
lives. This scourge did not discriminate, crossing every geographic and
racial boundary, with the largest increases among middle-class whites living
in nonurban areas.8

Scheduled (Controlled) Prescription Drugs

The drugs posing the greatest risk for misuse, overuse, and addiction are the
“scheduled” (controlled) drugs.
The Food and Drug Administration (FDA), working under the
Controlled Substance Act (CSA), has organized a subset of prescription
drugs into a category called “scheduled drugs.” Scheduled drugs are drugs
that have the potential for addiction and/or physiologic dependence. The
FDA has delineated a grading system from one to five within the scheduled
drugs, with schedule I drugs being the most addictive and schedule V drugs
the least addictive. All drugs in schedules II through V are thought to have
medical benefit in some situations and can be prescribed by a doctor with a
special license. Schedule I drugs, according to federal classification, have
no medical benefit and thus cannot be prescribed by a doctor under any
circumstances.
Examples of schedule I drugs include heroin, lysergic acid diethylamide
(LSD), 3,4-methylenedioxymethamphetamine (“Ecstasy”), and—brace
yourself—marijuana. Despite federal classification of marijuana as a
schedule I drug, it is widely available in more than twenty states through
medical marijuana dispensaries, putting state and federal regulations in
direct opposition.
Schedule II drugs include most of the opioid painkillers. Doctors can
typically give no more than a month’s worth of schedule II medication at a
time, with no refills allowed. Examples include morphine, opium, codeine,
hydrocodone (brand name Vicodin), hydromorphone (Dilaudid), methadone
(Dolophine), meperidine (Demerol), oxycodone (OxyContin, Percocet), and
fentanyl (Sublimaze, Duragesic). Vicodin and similar products were
reclassified from schedule III to schedule II with the Safe Prescribing Act of
2013, in recognition of the widespread misuse of Vicodin products in the
1990s and 2000s.
 Stimulants, which are also considered to be highly addictive, are in
schedule II. They are most often used in the treatment of attention deficit
hyperactivity disorder (ADHD) and include amphetamines (Dexedrine,
Adderall) and methylphenidate (Ritalin).
Schedule III includes buprenorphine (Suboxone), ketamine, and
anabolic steroids such as Depo-Testosterone. Doctors can provide limited
refills of these medications with one prescription, unlike schedule II drugs.
Schedule IV drugs include the important subgroup of the sedative
hypnotics, so-named because of their use in the treatment of anxiety and
insomnia. Benzodiazepines are a class of drug within the sedative-
hypnotics, including but not limited to alprazolam (Xanax), clonazepam
(Klonopin), diazepam (Valium), lorazepam (Ativan), midazolam (Versed),
and temazepam (Restoril). Examples of other schedule IV drugs are
carisoprodol (Soma) and zolpidem (Ambien).
Schedule V drugs consist primarily of preparations containing limited
quantities of opioids. Examples of schedule V drugs include cough
preparations containing not more than 200 mg of codeine per 100 ml
(Robitussin AC, Phenergan with Codeine).
The majority of prescription drugs remain unscheduled because they are
deemed nonaddictive. However, an unscheduled drug can become
scheduled if, over time, its addictive potential comes to light. Such was the
case with tramadol, a centrally acting painkiller first approved as an
unscheduled drug for use in the United States in 1995 under the name
Ultram. The Drug Abuse Warning Network (DAWN), a federally operated
national surveillance system that monitors trends in drug-related emergency
department visits, reported a 165 percent increase—more than 12,000 cases
—in drug-related emergency department visits mentioning tramadol from
1995 to 2002.9 In 2014, the Drug Enforcement Agency (DEA) rescheduled
tramadol to a schedule IV drug,10 thereby communicating its addictive
potential to doctors and consumers. Tramadol when first ingested has
limited opioid painkiller properties, but it is quickly metabolized by the
body into a more potent, and hence addictive, opioid painkiller.

A Tangled Web
This book is my attempt to understand how well-meaning doctors across
America—most of whom became doctors in the first place to save lives and
alleviate suffering—ended up prescribing pills that are killing their patients,
and how their patients, seeking treatment for illness and injury, ended up
addicted to the very pills meant to save them. More importantly, why do we
keep prescribing and consuming these dangerous drugs, even though we
know better?
In writing this book I have drawn upon my twenty years of clinical
experience seeing patients, as a psychiatrist and an addiction medicine
specialist. I have also conducted interviews nationwide with doctors,
nurses, pharmacists, social workers, hospital administrators, insurance
company executives, journalists, economists, and advocates, as well as
patients and their families.
The chapters that follow are framed around the story of my patient Jim.
Jim’s story encapsulates the enormity and complexity of the prescription
drug problem. It spans the period of time before and after a major
crackdown on prescribing opioid painkillers, reflecting how some of our
attempts to address this epidemic have helped, whereas others have led to
new problems. The stories of other patients—Justin, Karen, Sally, Macy,
and Diana—are interspersed throughout, in varying degrees of depth and
detail, in what I intend as useful digressions to illustrate or elaborate on
certain aspects of the prescription drug epidemic. The stories are true; only
the names have been changed. My patients have given me permission to
share their stories with you.
What I have discovered in the course of my work is that doctors and
their patients are caught in a web not entirely of their own making,
compelled by forces beyond their control to overprescribe and overconsume
prescription drugs. Only by teasing apart the strands of this web can we
untangle it and find a way out.
*
“Substance” is the generally accepted medical term for any addictive chemical. “Substance use
disorder” is the term for addiction found in the American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders.
*
Opioids (o-pee-oyds) are powerful painkillers (pain relievers) used for centuries to relieve pain.
Opioids work by binding opioid receptors in the brain and blocking pain signals. We have opioid
receptors in our brains because we make our own opioids, called endorphins, to block pain.
Endorphins work only for minutes at a time, whereas the newly synthesized pain relievers like
OxyContin, work for many hours, and bind the opioid receptor more strongly. Originally derived
from the poppy plant as opium, many opioids today are synthesized, or partially synthesized, in the
laboratory. By changing the chemical composition of naturally occurring opioids, scientists work to
create new and better opioids to treat pain. Their efforts have also been driven by the goal of creating
an opioid that targets pain without creating addiction. These efforts have met with mixed results.
 1

What Is Addiction, Who’s at Risk, and How Do

People Recover?

Born in sun-speckled California in 1952, Jim learned how to drink from his
father, a “three-martini-lunch” man who preferred his liquor served up dry
from a tall bottle of Old Grand-Dad bourbon whiskey. Jim remembers that
bottle, taller than your average whiskey bottle, with a picture of a dapper
older fly fisherman on the label, a rod in his lap, a raised glass of whiskey
in his hand, and just a hint of mischief in his smiling eyes.
Jim’s parents owned a San Francisco Yellow Cab company. His mother
worked the cage, assigning rides, tracking fares, keeping the books. His
dad’s job?—going to lunch. Jim’s dad dressed up every morning in a suit
and tie and met the “boys” at the local watering hole. Jim believes this
division of labor suited his parents. His dad was someone who “liked being
taken care of,” and he had a special knack for finding people who enjoyed
doing just that.
When Jim was 14, his dad started taking him to the occasional lunch,
where he got to sit on a high stool and listen to the older men talk. He got
his own drink, too. He couldn’t “put away” three martinis yet, but he might
get through one in an afternoon. Years before the word “alcoholic” became
part of Jim’s vocabulary, and decades before Jim would look back and
realize his father had been one, his dad was his hero.
After high school, Jim attended the Lincoln School of Technology,
where he learned automotive repair. When he graduated, his dad helped him
acquire an auto shop. It was the 1970s, and awareness of greenhouse gases
was taking off in California. Jim figured that smog testing was going to be a
huge unmet need in the Bay Area, so he decided to sit for his smog-testing
license exam. Jim studied hard for the smog-control certification test, and
when he found out he had passed, his father was the first person he told.
 “This,” his father declared, “is cause for celebration.”
Jim’s dad was good friends with the local chief of police, a prominent
man in the community who, more importantly, owned an RV. To honor
Jim’s accomplishment, Jim, his dad, the chief, and another friend, Kenny,
drove from the Bay Area to the Monterey Peninsula for a weekend of golf.
To be specific, the chief drove the RV while the other men sat in the back
and drank. They drank from the first turn of the wheel out of the driveway,
through every green on the golf course, and all the way home again.
One moment in particular about that trip stands out in Jim’s memory.
The chief was driving. Jim, his dad, and Kenny were sitting in the back,
pleasantly drunk. Jim thought about his exam score and his new automotive
repair shop. He looked around at the RV, with its shag carpet, foldaway
couch and table, and swivel chairs, complete with plaid upholstery and a
cup holder for his Schlitz—not to mention the bathroom and the kitchen
right there in the car—and he experienced a deep sense of well-being and
hopefulness about the future. “My life is perfect,” he thought, “real first
class.”
Jim spent the next twenty years trying to recapture that moment.
In no time Jim’s business was booming, with back-to-back
appointments for smog testing all day long. He was making money and
growing the business. He started drinking every day. Contrary to the myth
that heavy substance use is always a way of coping with life’s challenges,
that is, some form of self-medication,11 Jim’s alcohol use escalated when
his life was going well. At first he was just drinking in the evenings, but
before long he started going to the bar around the corner at lunchtime,
spending most of the afternoon there and skipping appointments at the
shop.
There were still mostly good times in those early days, like the time a
Rolls Royce broke down in front of his shop and the owner left it with Jim
for a day to be repaired. Jim fixed it, then called up his cousin, a dead ringer
for Hank Aaron, and told him to get over to the shop as fast as he could. He
called the guys at the bar to let them know Hank Aaron was in his shop and
coming over to sign autographs. When Jim’s buddies saw “Hank” step out
of that Rolls, they broke out in whoops and hollers. It wasn’t till an hour
into drinking that they guessed the truth, but by then it didn’t much matter
that they’d been had.
 As time went on, Jim’s drinking began to adversely impact his physical
health and his business. He was waking up in the morning with the shakes,
already craving the time when he could take his first drink of the day. The
shop was becoming disorganized and Jim more unreliable. After less than a
decade, Jim was forced to sell the business for nothing more than parts. As
he put it, “I drank the business away.” He wasn’t yet 30 years old.
After losing his business, Jim took a job at his parents’ Yellow Cab
company, fixing the cabs that came in for repair. His drinking was
unchanged, but the pressures of running a business were gone. As the
owner’s son, he got special treatment. No one commented if he showed up
late or left early. By his own admission, “A lot of people covered for me
and I got away with doing a lot less work.” Instead of repairing cars, he was
spending most of his time at the Green Hills Country Club in Millbrae,
where his father, a member, helped get him a membership of his own. As
Jim describes the club, “It was a bar with a golf course attached.”
Jim made a group of friends at the golf club, all of whom were heavy
drinkers like himself. They’d play a round of golf together, and winners
would buy drinks. Then losers would buy drinks. Then, “chipmunks would
buy drinks.” At that time, neither Jim nor his many drinking buddies at the
golf club would have identified themselves as having a drinking problem.
As Jim moved into his early forties, he no longer felt safe to drive
himself home from the club. He’d been driving drunk for years but had
never felt unsafe before. Now even he recognized that he was often too
drunk to drive. He’d go around the golf club looking to bum a ride, but
pretty soon his friends were making excuses not to drive him home.
Jim managed to get home somehow, and once there, he’d collapse into
bed in an alcohol-fueled haze. When he woke in the morning, he’d struggle
to remember where his car was. Had he driven himself home, or had
someone given him a ride? When he couldn’t find his car parked on the
street outside his house, he’d call up one of the drivers from the cab
company to give him a ride to the club. He frequently found himself
standing alone at ten in the morning in a nearly empty parking lot next to
his abandoned car.
Jim was running out of friends. He was running out of money. Most
importantly, alcohol just wasn’t working for him the way it used to. He kept
trying to recapture that peak experience when he was 22, traveling in the
RV to play golf at the coast. But no matter what he drank, how much he
drank, or who he drank with, he just couldn’t re-create it. After nearly
twenty-five years of regular heavy use, drinking alcohol went from being a
purely pleasurable experience for him to being something he did in solitary
misery.
Around the time Jim turned 47 years old, his closest buddy at the
country club died of an alcohol-cocaine overdose. Jim, who had already
begun to think seriously about quitting drinking, had new motivation. He
didn’t want to die. But how to stop? He couldn’t imagine it.
Across the street lived a man Jim affectionately called “Larry the
Limey.” Larry was a British World War II Air Force veteran and a self-
declared “reformed drunk,” actively involved in Alcoholics Anonymous, or
AA. One day Larry approached Jim and simply said, “Jim, there’s a better
way.” He invited Jim to attend his all-male Wednesday night AA meeting,
and Jim went.
Jim instantly hated AA. “What am I doing here in this lonely dungeon
of drunks, when someone like me should be sitting on a bar stool at the
Green Hills Country Club?” But despite Jim’s aversion to affiliating with
“drunks,” and his sense that he wasn’t one of them, he decided, as a kind of
experiment, that he would go, just to see what it was like. Sometimes he
showed up intoxicated, which was okay with the other men and consistent
with AA membership requirements, which asks only that potential members
come to meetings with the “desire to stop drinking.” To his surprise, Jim
discovered that more Wednesdays than not, when he went to an AA
meeting, he didn’t drink. In between he was still spending most of his time
intoxicated. Jim became a fixture at Larry the Limey’s all-male Wednesday
night meetings, and when he turned 50, Jim decided to walk away from
booze for good. “It was the hardest thing I ever had to do, and AA made it
possible.”
The first year after Jim stopped drinking, he was surprised at how much
better he felt. He starting exercising, and although he continued to go to the
country club on an almost daily basis, he was spending his time improving
his golf game instead of sitting in the bar. He went back to playing the
drums, a hobby from his teenage years. He bought a new drum set and even
joined a band. He also felt a terrific sense of freedom in those early years of
sobriety: he could finally go out to places where they didn’t serve alcohol
and spend time with people who didn’t drink and still have an okay time.
 His parents sold the Yellow Cab company, but he was kept on as general
manager because his work performance, once he had stopped drinking, was
exemplary. He spent more time with his wife and kids, whom he’d largely
neglected until then, even as he tolerated his regret about not having been
there for them earlier. It was a new millennium, and life was good, and it
would continue to be good for a decade. That is, until prescription
painkillers found Jim.

What Is Addiction?
In contemporary Western medicine, doctors rely on the Diagnostic and
Statistical Manual of Mental Disorders (DSM), a compendium of many
different types of mental illness, to diagnose addiction (substance use
disorders*).12 The DSM diagnostic criteria for addiction can be remembered
simply as the three “C’s”: control, compulsion, and consequences. Control
refers to out-of-control use, especially using more of a substance than
intended. Compulsion refers to spending a great deal of time, energy, and
thought (mental real estate) obtaining, using, and recovering from the use of
substances. Consequences refers to the social, legal, economic,
interpersonal, and moral or spiritual repercussions of continuing to use.
According to these diagnostic criteria, Jim was certainly addicted to
alcohol, with out-of-control use (drinking until he couldn’t drive himself
home), compulsive use (progressing to daily drinking), and consequential
use (losing his smog testing business).
Jim also manifested the physiologic phenomena associated with, but not
necessary for, a diagnosis of addiction: dependence and withdrawal.
Physiologic dependence is the process whereby the body comes to rely on
the drug to maintain biochemical equilibrium. When the drug is not
available at expected doses or time intervals, the body becomes
biochemically dysregulated, which manifests as the signs and symptoms of
withdrawal. Withdrawal is the physiologic manifestations of not having the
substance, the symptoms of which vary from substance to substance. As a
general albeit oversimplified principle, the characteristics of withdrawal
from a given substance will be the opposite of intoxication for that
substance. For example, intoxication with alcohol includes euphoria,
relaxation, lowered heart rate, lowered blood pressure (mild), and sedation
(sleep). Withdrawal from alcohol includes dysphoria (unhappiness),
agitation, restlessness or tremor, increased heart rate, elevated blood
pressure, and insomnia. Even in the absence of physiologic withdrawal,
cessation of all addictive substances after sustained habitual use is
characterized by insomnia, dysphoria, irritability, or anxiety. In the case of
withdrawal from some substances, for example alcohol, seizure and even
death are a possibility.13
According to neuroscientists, addiction is a disorder of the brain’s
reward circuitry. Survival of the species depends on maximizing pleasure
(finding food when hungry, for example) and minimizing pain (avoiding
noxious stimuli). Seeking out pleasure and avoiding pain is adaptive and
healthy. The intense pleasure experienced with addictive drugs,14 and
importantly the memory of those pleasurable experiences15 and the desire to
re-create them, is what prompts reuse. Jim’s magical RV ride after passing
his exam is a prime example of this. Indeed, many people who later go on
to develop a substance use disorder describe a vivid positive experience
with their early exposure to drugs or alcohol.
If only the brain’s reward circuitry would continue to respond the way it
does the first time. Unfortunately, with sustained heavy use, the brain
undergoes biochemical changes that keep the substance from having its
desired effect, and the individual needs more and more to get the same
response (tolerance).16, 17 The individual who is vulnerable to addiction will
commit all available resources to obtaining more of the substance,
overcoming tolerance, and re-creating its original effect, even forgoing
natural rewards like food, finding a mate, or raising children. Over time the
substance itself is mistaken as necessary for survival.14 (For more on the
neuroadaptation of addiction, see chapter 5.)
Context and culture also play a role in diagnosing drug and alcohol use
disorders.18 Cross-cultural studies readily demonstrate many “wet” cultures
across the world whose members drink as much or more than Jim and his
golf buddies were drinking but which do not consider such behavior
pathological.19 Some ethnographers claim that addictive alcohol
consumption does not occur to a significant extent in small-scale
preindustrial societies.20
 Who’s at Risk?
A perennial question about addiction is why some people exposed to drugs
and alcohol can use them in moderation without ill effects, whereas others
go on to become addicted, with all the tragic and often life-threatening
consequences that entails. Although no one knows for sure what causes
addiction, decades of accumulated evidence point to certain risk factors,
which can broadly be divided into three categories: nature, nurture, and
neighborhood.
Nature. There is good evidence that vulnerability to addiction is
heritable, passed down within a person’s genetic code from one generation
to the next. The data show that having a biological relative (parent or
grandparent) with addiction increases the risk of becoming addicted, and
that genetics accounts for between 50 and 70 percent of that risk,21 a high
percentage compared to the currently known genetic contribution in other
mental disorders such as depression (30 percent).22 Genetic risk for
addiction appears to be independent of upbringing, as shown by adoption
studies of children raised outside the drug-using home.
The mechanism by which vulnerability to addiction is passed down in
the genetic code is not known and is likely to involve complex genetics,
dependent on many genes coding for different traits. Emotion dysregulation
(experiencing emotions with more intensity and for longer than average
duration) and impulsivity (the tendency to act on thoughts or emotions
without weighing the consequences) have both been shown to be highly
heritable traits,23 and are associated with the later development of
addiction.23–26 Iacono and others have described addiction as an interaction
between two neural systems, one that communicates the rewarding
properties of an object and another that allows for reflective rather than
impulsive behavior.23
One way to think about this is to imagine the brain as a car, with a gas
pedal and a brake. The limbic system, the emotion processing part of the
brain, is the gas pedal, propelling the individual to action and motion. The
frontal lobe, the future-planning part of the brain, is the car’s brakes, telling
the individual when to slow down, stop, and reevaluate. Addiction appears
to arise from a fundamental problem in the brain’s ability to control its gas
pedal and/or its brakes, usually along the lines of too much gas and faulty
brakes.
Nurture. We know that children raised in families where using addictive
substances is modeled and even encouraged, are at increased risk of
developing a substance use disorder,27 as in Jim’s family. Substance use is
more likely to occur in adolescents who affiliate with so-called deviant
peers.28 Early childhood trauma increases the risk of addiction. High
conflict between parent and child, lack of parental involvement in the
child’s life, and lack of parental monitoring,29, 30 also appear to be
developmental risk factors.31, 32 By contrast, Jim’s parents were supportive,
loving, and actively engaged in his life. Paradoxically, in his case, his close
relationship with his father, a heavy drinker, may have complicated Jim’s
relationship with alcohol, contributing to his own later struggles with
addiction.
Neighborhood. The risk of substance use, and hence the development of
a substance use disorder, is strongly related to the sheer availability of
addictive substances. If an individual lives in a neighborhood where drugs
are sold on the street corner, that individual is more likely to experiment
with, and get addicted to, those drugs. The classic example of this is
American soldiers in Vietnam, many of whom used heroin regularly while
in Vietnam, but stopped or greatly curtailed their use after returning to the
United States.33
This risk factor has particular relevance for today’s prescription drug
epidemic. The increased availability in the 1990s and 2000s to addictive
drugs through a doctor’s prescription, suddenly increased the risk of
addiction to a growing population of patients being prescribed these drugs,
not to mention the larger population with access to these drugs through
friends and family members.
According to the July 2014 Morbidity and Mortality Weekly Report, US
prescribers wrote 82.5 opioid painkiller prescriptions and 37.6
benzodiazepine prescriptions per 100 persons in 2012.34 Data compiled by
the Substance Abuse and Mental Health Services Administration show that
the majority of misused prescription drugs is obtained directly or indirectly
from a doctor’s prescription; only 4 percent of persons misusing or addicted
to prescription drugs reports getting them from a drug dealer or a stranger.35
A study in The Journal of Pain (2012) showed that the number one
predictor of rates of opioid prescribing in a given geographic region in the
United States is the number of available physicians, unrelated to the
prevalence of injuries, surgeries, or other conditions requiring treatment for
pain.36

How Do People Recover from Addiction?

How do people stop using substances once they have become addicted to
them? The neuroscientist Roy Wise, who studies addiction in animals, says
that the only way an addicted animal will stop using drugs is if the drug is
no longer available, the animal is too physically exhausted to administer the
drug, or the animal dies.17 Humans are clearly different from animals, and
complex psychological, social, and spiritual factors play a role in the
decision to initiate as well as to stop using substances. Jim was indeed
getting exhausted, but he wasn’t near death, and alcohol was still freely
available. Jim believes joining AA made the difference in his case.
Three decades of accumulated scientific evidence demonstrate that AA
works37—not for everybody, and not all of the time, but those who
participate in AA get as much benefit or more as those who receive
professionally administered treatments like cognitive behavioral therapy
and motivational enhancement therapy, and at a much lower cost, because
AA is free.38 One of the ways AA works is by changing social networks.
AA changes behavior through facilitating social contacts with supportive,
nondrinking peers, that is, reducing pro-drinking influences and providing
abstinent role models.39 For a gregarious man like Jim, this makes sense.
When Jim gave up drinking, he was not just giving up alcohol. He was also
giving up his earliest and most fundamental conceptualization of how men
socialize with other men. AA provided a solution to this problem: an
alternative social network in which drinking didn’t occur. It was probably
not insignificant that Jim’s first introduction to AA was an all-male group.
But AA and other self-help groups for addiction don’t work for
everyone, and they are not the only way. Some patients do better with
individual therapy. Some do better with medication. Most end up using
some combination thereof. And some patients recover on their own, with no
professional or self-help group intervention at all.40 What is increasingly
clear is that addiction for many is a life-long struggle, requiring life-long
treatment or monitoring.
*
The language of addiction is in flux, and some people argue that the term “addiction” should be
used only to describe the more severe forms of substance use disorder. Furthermore, not all addictive
disorders involve substances, for example, sex, gambling, and Internet addictions. Nonetheless, for
simplicity’s sake, I use “addiction” here interchangeably with “substance use disorders.”
 2

Prescription Drugs as the New Gateway to

Addiction

In 2012, when Jim turned 60, he developed an infection in his lower back.
He went to the Emergency Department at a Bay Area hospital, where he
was admitted and given intravenous antibiotics to fight the infection. He
also received intravenous morphine, an opioid, to fight the pain.
Jim experienced immediate pain relief from the intravenous morphine,
and something else—that sense of well-being that he remembered so well
from his early days of alcohol, an energized but peaceful clear-headedness,
without worry or doubt. He was instantly under its power.
The rapidity with which Jim became addicted to morphine—possibly
after a single dose—speaks to the phenomena of reinstatement and cross-
addiction. Neuroscientists speculate that brain changes that occur after
continuous heavy use of addictive substances can cause damage that does
not resolve even after years of abstinence. One of the ways these
irreversible changes can manifest is that the brain is primed to relapse to
addictive physiology even after a single exposure to the addictive
substance.41 This is called “reinstatement” by neurobiologists, and
“relapse” by those who are addicted.
Reinstatement is not triggered solely by the substance that the
individual was previously addicted to. Reinstatement can occur with any
addictive substance because all addictive drugs work on the same brain
reward pathway.42 For example, animals repeatedly exposed to the
addictive component of marijuana (tetrahydrocannabinol, or THC) and then
not given THC for a period of time become addicted to morphine more
quickly than animals not previously exposed to THC.43 This phenomenon is
called cross-sensitization, or cross-addiction. The intense high and craving
that Jim experienced after a single dose of morphine was likely the result, at
least in part, of reinstatement and cross-addiction.
Although a history of addiction increases the risk of becoming addicted
to opioid painkillers prescribed by a doctor,44 many people with no
addiction history can become addicted to opioid painkillers in the course of
routine medical treatment.45 Furthermore, they can become addicted
quickly, in a matter of days to weeks, just as Jim did. This is contrary to
what doctors were told in the 1980s, 1990s, and early 2000s, when a pro-
opioid movement in the medical pain community encouraged doctors to
prescribe opioids more liberally and reassured them, based on false
evidence, that the risk of becoming addicted to prescription opioids among
patients being treated for pain was less than 1 percent46 (see chapter 4).
More recent studies reveal that as many as 56 percent of patients receiving
long-term prescription opioid painkillers for low back pain, for example,
progress to addictive opioid use, including patients with no prior history of
addiction.47
The gateway hypothesis of addiction posits that using cigarettes and
alcohol, which are legal drugs, leads to experimentation with other,
“harder” drugs, like cocaine and heroin. Whether this progression is due
simply to opportunity costs and ease of access,48 or to some more
fundamental biological mechanism based on the chemical composition of
the drug itself,49 is still being debated.
In today’s world easy access to “harder” drugs through a doctor’s
prescription has turned the gateway hypothesis on its head. For increasing
numbers of people, especially young people, prescription drugs are the first
exposure to addictive substances and the first stepping-stone to future
addictive use. My patient Justin’s story provides an example of how a
potent and addictive drug prescribed by a doctor can become a gateway to
addiction.

Vicodin: A Gateway Drug

Justin had none of the classic risk factors of nature or nurture that we
typically associate with increased risk of addiction. The only child of
educated upper-middle-class Jewish parents, neither of whom (unlike Jim’s
parents) smoked, drank, or used drugs, and with no family history of
addiction, he seemed at average risk. (A prevailing misconception is that
Jewish people are at lower risk than other ethnic groups for substance use
disorders. As told so well by Rabbi Shais Taub in the introduction of his
excellent book God of Our Understanding: Jewish Spirituality and
Recovery from Addiction, there are no data to support this stereotype.)50
Justin’s childhood was also without trauma. His parents were loving,
kind, and devoted to his well-being. He was in good physical health.
Sometimes he was teased about his weight—he’d always been pudgy—but
he never felt bullied. He had friends. He was neither impulsive nor prone to
excessive emotionality. If anything his emotional expressions were muted.
He was smart and schoolwork came easily to him. He especially liked
science. He fondly remembers dissecting a cow’s eye, and mixing
cornstarch and water to make “oobleck,” in the fourth grade. Anything
having to do with computers was always of interest, in particular building
computers and playing video games. He grew up in his parents’ single-
family home in a white middle-class suburb of San Francisco.
The risk factor that Justin encountered, contributing to his later
development of addiction, had everything to do with neighborhood, and not
neighborhood in the strict sense of geography, but neighborhood in the
sense of context, culture, and technology. Justin, like many teens today,
especially compared with previous generations, had early exposure to
scheduled drugs (opioids) through a doctor’s prescription, thereby
developing a “taste” for them, followed by virtually unlimited access to
drugs through peers at school and on the Internet.
During his sophomore year in high school, Justin went to the dentist to
get his wisdom teeth removed. He lay back in the dentist’s chair, the bright
white lights slowly fading into blackness as he lost consciousness from the
concoction of drugs the dentist had given him. When he awoke, it took him
a moment to realize where he was. He heard the high-pitched whine of the
drill and smelled the pungent odor of burnt enamel, and then he
remembered: wisdom teeth. Despite his mouth being pulled apart by several
sets of hands and a metal drill spinning near his flesh, he felt good—
incredibly good, like no kind of good he could remember ever having felt
before. He soon floated back into unconsciousness.
In the waiting room after the procedure was over and the drugs had
mostly worn off, Justin felt nauseated, and his mouth was sore. Through a
residual haze of the drugs’ effect, he saw the dentist write out a prescription
for Vicodin for pain relief. The dentist explained that Justin should take one
pill every four to eight hours as needed for pain.
Once Justin and his mother arrived home, he took one pill and put the
rest on his bedside table. He immediately felt relief from the pain in his
mouth—and something else—an echo of that good feeling, that better-than-
normal-for-him feeling. He lay in bed and again drifted off to sleep.
In the days that followed, Justin took one Vicodin every four hours. On
the surface of things, his life had returned to normal. He was back at school,
going through the motions of being an average high school student at the
average California public high school in the mid-2000s. But inside, under
the influence of Vicodin, he felt energized, worry free, and completely at
ease with himself. He recalled the man who had visited their third-grade
classroom to talk to them about the dangers of drugs and alcohol—part of
the DARE project.* The man had told them that people took drugs to alter
mood, to “feel good.” Justin knew the man had meant it as a warning, but
thinking about it now, the idea sounded like pure genius.
Justin began doubling up on the Vicodin, seeking to maintain the good
feelings that had started to wear off with repeated use. When he ran out of
his prescription, he asked his mother to take him back to the dentist to get
more, telling her he still had pain. (His pain was mild and tolerable. What
he was really looking for was a way to extend that sense of well-being that
Vicodin provided.) His mother took him back to see the dentist, and the
dentist readily prescribed Justin another month’s supply. It surprised Justin
how easy it was to get a refill and that no one questioned his motives.

An Epidemic of Overprescribing
The prescription drug epidemic is first and foremost an epidemic of
overprescribing. Potions and elixirs have always been part of a doctor’s
trade, but 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.
In 2012, some 493,000 individuals aged 12 or older misused a
prescription drug for the first time within the past twelve months,35 an
average of 1,350 initiatives per day. Of those who became addicted to any
drug in the previous year, a quarter started out using a prescription
medication: 17 percent began with opioid pain relievers, 5 percent with
sedative-hypnotics, and 4 percent with stimulants.35 Prescription drugs now
rank fourth among the most-misused substances in America, behind
alcohol, tobacco, and marijuana; and they rank second among teens.
Teens are especially vulnerable to the increased access to prescription
drugs. Adolescence is a time when the rapidly growing brain is more
plastic, and therefore more vulnerable on a neurological level, to potentially
irreversible brain changes caused by chronic drug exposure.51, 52 Teens are
more vulnerable to social contagion pressures to experiment with drugs.
Also, most importantly, ready access to heroin and methamphetamine
equivalents in pill form has blurred the lines between soft and hard drugs
for today’s youth.
When the second refill ran out, Justin was reluctant to ask for more. But
despite daily use for more than a month, he didn’t suffer any acute physical
opioid withdrawal. However, that single exposure to opioid painkillers set
him on a new course. He began experimenting with a variety of prescription
pharmaceuticals, which was normative among his peers, who generally
viewed prescription pills as safer than illegal drugs. He obtained all his pills
from school friends, mostly for free, but sometimes for cash. His friends got
pills from a combination of doctors, relatives, and drug dealers. Justin liked
prescription opioid painkillers best of all.
Justin ingested drugs almost exclusively during school hours, so by the
time he went home, the effects had worn off and his parents didn’t notice.
Amazingly, neither did his teachers. One day in the middle of class, Justin
took SOMA, a potent muscle relaxant. As he began to feel its effects, he
had an uncontrollable desire to stretch out and extend his muscles. Sitting at
the back of the class, he began gyrating in circles with his upper body,
leaning far over his desk, to the right, then the left, then backward, almost
sliding off his chair in the process. As he remembers it, no one noticed, or at
least no one commented. Either way, it’s disconcerting to think such
behavior can go unremarked.
Justin was slated to graduate from high school in 2006, but he failed an
English class his senior year, and never got around to making it up. Instead
he spent the next couple of years hanging out with friends and using drugs,
mostly cannabis, alcohol, and whatever pills they could easily get from one
another. He took a couple of classes at the community college, but didn’t
really apply himself. He finally took and passed his GED in 2009.
His parents weren’t sure what to make of his desultory lifestyle in those
years after high school. Justin believes they knew about the marijuana,
which they were okay with because his dad had used pot on weekends in
his youth; but they were oblivious to Justin’s use of other drugs and to the
extent of the pot use, and they were unaware that the pot Justin smoked was
much more potent than anything his dad had access to in the 1970s.
It’s easy in retrospect to condemn parents who seem not to notice that
their kids are using drugs, but I’ve met too many caring parents over the
years to stand in judgment. Kids using drugs go to great lengths to conceal
their use, and even watchful parents can miss the signs.

Cyberpharmacies
After high school, Justin gradually lost contact with his drug-sourcing high
school friends and thereby lost a ready supply of pot and pills. Being risk-
averse by nature, he was reluctant to seek out drug dealers, try to get drugs
from doctors by feigning illness (doctor shop), or do anything else overtly
illegal to get drugs. Instead, he discovered a new source that was
convenient, cheap, and didn’t require him to leave the safety and comfort of
his own home: the Internet.
Justin’s parents were both at work, and though he was supposed to be
spending time online looking at courses to enroll in the local community
college, or looking for a job, he was instead typing “Vicodin,” still his drug
of choice, into Google. That query pulled up links for online pharmaceutical
companies. He clicked on Top Ten Meds Online, which looked like a
legitimate pharmaceutical company, but just to be sure, he googled it on
SafeorScam.com, an online resource that would tell him whether this site
was some kind of sting operation or scam. It checked out, so he went back
and searched for Vicodin. None was available. Next, he typed in “opioids”
and found codeine as a cough medicine. He put it in his cart. He typed in
“tranquilizer/hypnotic” and put Valium and Xanax in his cart. Just before
heading to checkout, he added the dissociative anesthetic ketamine. He
entered his credit card information and clicked the purchase button. Within
the week, his “medications” were shipped to his house, delivered by FedEx,
no prescription required.
Law enforcement agencies first became aware of online pharmacies
selling controlled substances without a prescription in the mid-1990s,
coinciding with reports on the rapid increase in prescription opioid abuse
and misuse and prescription opioid–related overdoses, especially among
young people. These websites conduct business in the United States in
direct violation of the United States Controlled Substance Act (CSA).
Despite operating in violation of the CSA, websites that sell controlled
medications without a prescription are difficult for law enforcement to
monitor or prosecute. As described in the article by Forman and coauthors,
“The Internet as a Source of Drugs of Abuse,” the web page for such a site
may be physically located in Uzbekistan, the business address in Mexico
City, money generated from purchases deposited in a bank in the Cayman
Islands, the drugs themselves shipped from India, while the owner of the
site is living in Florida. Law enforcement from multiple countries would
have to collaborate to enforce and prosecute the owner of a single site, and
the entire operation can be dismantled, erased, and reestablished elsewhere
in a single day.53 Furthermore, marketing techniques used by the sites make
it difficult to find them. Some of these no-prescription online sites
camouflage themselves as something other than a drug-selling site. One
such site went by the name “Christian Site for the Whole Family,” with
links to “bible study group” and “Easter Drugs Sale: Buy Codeine without a
Prescription.”53
The international nature of the drug trade today gives the old opium
wars, as commented on by Walsh, a new twist, wherein cyberpharmacists
are drug dealers for the modern age.54 Support for this claim comes from a
report out of Columbia University, which gathered data showing that 11
percent of the prescriptions filled in 2006 by traditional (brick and mortar)
pharmacies were for controlled (scheduled) substances, whereas 95 percent
of the prescriptions filled by online pharmacies in the same year were for
controlled substances.55
The Internet is not merely a passive portal for controlled prescription
drugs. Once Justin, for example, has purchased drugs online, the site
remembers him and may send unsolicited e-mails alerting him to new
products or special deals. This aspect makes it especially difficult for
addicted individuals to stop using drugs. Short of changing his e-mail
address or utilizing filtering software, Justin cannot avoid being found and
targeted once again for drug use by Internet sellers.
Initially Justin looked only for prescription drugs through online
pharmacies, but gradually he became interested in new and experimental
drugs in the pharmaceutical pipeline, often sold as “research chemicals.” He
learned about new drugs by spending time on the website Pipemania.com, a
splinter group of Lifetheuniverseandeverything.com. Pipemania, one of
many Internet communities like it, is a forum where users talk about what
drugs they are using and what those drugs feel like, including lots of newly
synthesized drugs and newer drug combinations. People using these sites
refer to themselves as “researchers” and to their drug use experiences as
“research findings.”
Examples of newer synthetic drugs include Methoxetamine, or MXE, an
analog of the drug ketamine, labeled as a “research chemical product” and
taken for its hallucinogenic and dissociative effects. Purple Drank, or Lean,
another popular new mixture consumed primarily by young people,
combines Sprite, Jolly Ranchers, and codeine (an opioid). If prescription
codeine is unavailable, DM (dextromethorphan) cough syrup is often
substituted.
The buying and selling of illegal drugs, outside of online pharmacies,
occurs primarily in the “deep web,” a term used to refer to a clandestine
part of the network where online activity can be kept anonymous. Most of
these drug-selling underground sites use Bitcoin as their only currency,
providing customers with anonymous access to drugs from all over the
world, without even a pretense at legality. One such site, now dismantled,
was Silk Road, allegedly operated by 30-year-old Ross W. Ulbricht, who
went by the pseudonym Dread Pirate Roberts, a character from the movie
The Princess Bride. Mr. Ulbricht was recently convicted of narcotics
trafficking, computer hacking, and money laundering.

Heroin—the New Vicodin

In 2012, despite engaging in daily, now mostly solitary, drug use, Justin
attended community college and got a job at Oracle in the shipping
department. With his new job, he was suddenly in possession of cash, and
much more than he had become accustomed to with his parents’ allowance.
One night in the summer of that year, he went to a small get-together at a
friend’s house, where he met someone whose brother knew a heroin dealer.
Justin had never tried heroin before; he had always shied away from illegal
so-called street drugs and from drug dealers. But he was curious, and eager
to use opioids, which were increasingly difficult to obtain online in any
form. Through friends he met Sean, the man who would become his heroin
dealer, his business partner, and his housemate. Justin bought a gram of
heroin, telling himself it was no big deal; it was just an experiment, and he
could handle it.
Heroin was originally synthesized in 1874 by C. R. Alder Wright, an
English chemist working at St. Mary’s Hospital Medical School in London.
Wright added two acetyl groups to morphine to form di-acetylated
morphine, which was largely forgotten until twenty-three years later, when
it was independently synthesized by Felix Hoffmann in Germany.
Hoffmann, working at what is today the Bayer Group’s Pharmaceutical
Division, was instructed to find a less addictive alternative to morphine. Di-
acetylated morphine was marketed by Bayer alongside aspirin from 1898 to
1910 as a nonaddictive morphine substitute and cough suppressant, as well
as a cure for morphine addiction. Bayer named di-acetylated morphine
“heroin,” based on the German “heroisch,” which means “heroic” or
“strong.” Strong it certainly was. By the early 1900s an epidemic of heroin
addiction raged in the United States, prompting passage of the Harrison
Narcotic Act of 1914 to control the sale and distribution of heroin and other
opioids. Today in the United States, heroin is considered a schedule I drug,
meaning it is considered highly addictive and is not approved for any
medical purpose.
Justin intended to use his heroin sparingly, just now and then. Instead he
used it daily for two months, not stopping till he had run through the entire
$1,600 he had earned and saved from his job at Oracle. He lost his job and
quit school, unable to meet the demands of either. Then he went into acute
heroin withdrawal. He remembers heroin withdrawal as “the most horrible
feeling in the world, like you’re gonna die.” Elaborating further, “I
wouldn’t wish it on anyone, not my worst enemy.”
The number of Americans aged 12 and older who used heroin in the
past month rose from 281,000 to 335,000 between 2011 and 2013, a
significant increase from the 166,000 using heroin in 2002.56 According to
the Centers for Disease Control and Prevention, heroin-related overdose
deaths also rose in that time frame, with a 39 percent increase between 2012
and 2013 alone. The majority of new heroin users cite prescription opioids
as their first exposure to opioids,57 a clear generational shift. In the 1960s,
80 percent of opioid users reported that their first exposure to opioids was
in the form of heroin. In the 2000s, 75 percent of opioid users reported that
their first exposure to opioids was in the form of prescription painkillers.58
Increases in heroin use have been driven mostly by 18–25 year olds.
Justin went to Sean and told him he was out of money, but desperate for
heroin. Sean offered Justin an arrangement in which Justin would work for
Sean, and in exchange, get cheap access to heroin for his services. Sean
wanted Justin to sell for him, but Justin wasn’t willing. As an alternative,
Sean offered that Justin could work in “his lab,” an offer which Justin
accepted.
For the next nine months, Justin spent most of his time at Sean’s house,
running Sean’s lab. Sean lived in a rundown house in a rundown
neighborhood in East Oakland, a place with hardly any furniture besides a
TV, a plastic kitchen table with plastic chairs, and a couple of worn
mattresses. Justin had dropped out of school, unable to keep up with his
courses while strung out on heroin. He told his parents he was “staying with
a friend,” and he returned home every two or three days for a visit, just to
reassure them all was well.
On a typical day during those nine months between the summer of
2012, when Justin first tried heroin, and spring of 2013, when he would first
attempt to quit, Sean and Justin would wake up around one in the afternoon
and share a light breakfast. This breakfast did not consist of food; it
consisted of heroin. They both preferred snorting to injecting. They lined
the heroin up on a smooth, clean surface and passed it between them till
they were sated, just as if they were passing a basket of rolls. Sometimes
they “chased the dragon,” a way of ingesting heroin that requires putting the
heroin on a bit of tin foil, putting a source of heat—a match or a lighter—
below the foil, and inhaling the vaporized powder. The term “chasing the
dragon” refers to the plume of smoke that rises up off the foil, like a
mythical dragon’s tail, as well as the high that addicted persons seek, as
elusive as the mythical creature whose name it bears.
 Justin recalls that he was never hungry when he was using heroin. In
fact, he didn’t want anything. He didn’t want to eat, read, bathe, exercise,
watch TV, or even play his beloved video games. He was living in a
“dump” with no furniture, no food in the refrigerator, no family, no job, and
no prospects for the future, and despite the ever-present threat of legal
consequences from dealing in illegal drugs, he felt “complete.”
He spent his days cooking heroin from morphine, and when the stink of
the chemicals made his eyes burn, he joined Sean on the porch. Every hour
or two they snorted heroin. “Because we were distributors, we didn’t even
wait till we were feeling sick to use. We’d use to get even higher than we
already were.”

The First Step to Recovery

One day in the spring of 2013, Justin was sitting in Sean’s house filling
balloon bags of heroin for later sale, when he realized that he had been
using heroin daily for exactly nine months. “I was thinking in my head,
‘Wow, it’s been almost a year. If I let this year go by, it’s going to be five
years, ten years, maybe my whole life.’ ” At that moment he decided to quit.
He also recognized that he would not be able to act on his decision without
help, primarily due to the physiologic withdrawal associated with stopping
opioids.
Again he turned to the Internet. While the latest batch of heroin was still
cooking in the oven, Justin looked up treatment for heroin addiction on his
laptop. He found a website for BAART (Bay Area Addiction Research and
Treatment), a methadone maintenance treatment clinic in Oakland, and
immediately set up an appointment. (For a discussion of methadone and
Suboxone, opioid agonist treatments for opioid addiction, see chapter 5).
Justin recalls that BAART required their clients to be in active withdrawal
when initiating methadone, so he stopped using in the hours before his
appointment and was plenty sick when he went in and received his first
dose of methadone.
Justin also decided to tell his parents. He realized he’d have to be living
at home again, and traveling every morning to Oakland to get his
methadone dose, and there was all the paperwork he needed to fill out.
There was no way he could hide it from them any longer.
 The same day he started on methadone, Justin told his parents that
heroin was something he’d always wanted to try and thought he could
handle. He said he’d been sucked in, and he blamed no one but himself. He
knew his parents felt guilty anyway, as if they had failed him. Justin almost
cried remembering their conversation. “They were very supportive,” he
said. “They’ve always been very supportive.”
Justin did well on methadone. He enrolled at the community college
again, made new nonusing friends, and joined a study group. When he did
relapse six months after being in the BAART program, he relapsed hard—
which is common—and was smoking crack at the same time he was using
heroin. He dropped out of the methadone program at BAART, but bought
methadone on the street to ease his comedowns. For months he managed to
use crack and heroin on the weekends and methadone to get through his
classes during the week. One day, unable to reach his methadone source, he
started to go into withdrawal. “I realized ‘I’m at the whim of my dealer.’ ”
He bought some Suboxone, a medication with similarities to methadone,
also used to treat opioid addiction, from a friend, and used that the same
way he had used methadone, that is, to tide him over when he couldn’t get
heroin.
But Justin was getting tired. Tired of chasing down heroin, methadone,
and Suboxone. Tired of feeling anxious and sick, wondering if he’d have
enough drug to keep going. Tired of lying and living the double life—
pretending, as he says, “to be sober, but having this second actual life where
you’re keeping secrets from everybody, lying, and having to keep track of
all the lies. It’s all just so hard to keep up.”
Again he looked on the Internet, this time for someone to prescribe
Suboxone, which is how he found me. When he told me his story, I agreed
that Suboxone made sense, given the severity of his opioid addiction. But
Suboxone treatment requires close monitoring, including regular clinic
visits and urine toxicology screens to test for the presence of other drugs. If
other drugs are detected, I explained, ongoing Suboxone treatment might be
compromised. I also encouraged him to seek some kind of psychosocial
intervention to treat his addiction as well.
Justin agreed to Suboxone treatment and monitoring and to a Narcotics
Anonymous (NA) meeting. Unlike Jim, he did not find twelve-step groups
helpful; they just weren’t for him. He quit going after a few weeks. But
Justin came to appointments regularly and never tested positive for other
drugs, except for a couple of small slipups with benzodiazepines, the most
recent when, while cleaning his room, he came across an old stash of
Valium pressed between his bed and the wall. He took the Valium for sleep
for the next several weeks, then stopped. He felt guilty about it. A year later,
he is still doing well.

A Different Kind of Dragon

Justin ascribes his year of recovery from addiction to Suboxone, his
relationship with his parents, and interactive role-playing tabletop games.
“Suboxone stops the cravings and I can feel normal. I don’t lie anymore.
Role-playing games help by giving me the escape and excitement that I
would usually get from that whole street life.”
Today, Justin spends most of his weekdays studying. On the weekends,
he spends some time on the computer, but he no longer visits online
pharmacies or spends nearly the amount of time he used to playing video
games. Instead, with some sweet irony, he is much more likely to be on a
site called Penandpaper.com. There he is able to interact with other players
of so-called tabletop, or role-player games. Tabletop games simulate the
quest story lines so popular among video gamers, but without the video.
There is often an online version of the role-player games, but Justin much
prefers the face-to-face version. He claims the story is richer that way.
On a typical Saturday, Justin’s five tabletop teammates, now a stable
crew he meets with on a regular basis for gaming, come to his house around
eleven o’clock to spend the day playing. Collaborative storytelling is the
essence of the game. They sit around a table, sometimes for as long as eight
hours at a time, and together describe the world their characters will inhabit
and what will happen to them in that world. Sometimes they may even act
out a scene or engage in a small role-play, as if creating theater, though
none of them would ever describe themselves as actors.
They are currently playing ShadowRun, set in a futuristic world
populated by magical beings and cyborgs. Justin’s character is an Ork, a
troll-like creature with robotic enhancements and cybernetic abilities named
“J-Rez.” Their latest story line bears an uncanny resemblance to Justin’s
own life—and it can be read as the narrative of Justin’s alter ego.
 J-Rez has just heard from his female crime boss that his next mission is
to travel to Seattle to obtain a new synthetic drug called Novacoke. In
Seattle, J-Rez meets up with the other members of the organized crime ring,
and together they venture into a high-crime neighborhood to deliver a
package of research chemicals needed to make Novacoke. In exchange,
they get a sample of the drug to take back to their boss. However, right after
getting the package they came for, they are nearly killed by a detonated
bomb, saved only by J-Rez’s robotic enhancements. The team then combs
the neighborhood and, through diligent detective work, including
deciphering a tattoo, identifies their would-be killer—a man who has eluded
them because he has the ability to turn into a dragon. J-Rez and his gang
embark on their next assignment: chasing the dragon.
Justin continues to chase mythical creatures, but for now, not through
the medium of addictive drugs.

The Gateway Now a Runway

Young people today don’t just experiment with cigarettes, alcohol, and
marijuana. They try everything, especially if it comes in the form of a pill.
They even try chemicals newly synthesized in a laboratory without any idea
of what these chemicals might do to them. They obtain these drugs from
friends at school, from the Internet, from their own home chemistry kits.
The gateway, in other words, has become a runway, telescoping the
progression from recreational to addictive use. That first prescription for
opioids, stimulants, or sedatives is the boarding pass, in some cases, to a
lifelong struggle with addiction.
*
The unintended consequences of drug use education are salient here. Drug Abuse Resistance
Education (DARE) was a school-based prevention program, adopted throughout the United States in
the late 1990s and early 2000s, in which police officers provided information on the dangers of drug
use to students in the classroom. In retrospect, DARE was ineffective at preventing or even delaying
drug use, and in some cases it may even have promoted use, as exemplified by Justin’s experience.
DARE illustrates the broader challenge of using didactic and mass media educational campaigns to
target drug use.
 3

Pain Is Dangerous, Difference Is Psychopathology

The Role of Illness Narratives

Let’s return to the story of my patient Jim, whom we left in a Bay Area
hospital being treated for a lower-back infection. Jim’s doctors prescribed a
dose of morphine as needed every four hours, a standard order for patients
in the hospital struggling with severe pain and a time-saver for nurses and
doctors, allowing the nurse to administer pain relievers without having to
call the doctor back every time. For some patients, such an order is
compassionate care. For others, like Jim, that kind of order is poison.
By the second time the nurse came around with the morphine, Jim knew
what was coming, and he was already feeling the high just anticipating it.
He rested his head back on the pillow, proffered his left arm with the
percutaneous intravenous line ready and, taking a deep breath, thought,
“Now I’m going to feel real good, and I don’t have to be embarrassed about
it, because I’m a patient, and these are doctors giving me this drug.”
Of central importance here is the way Jim’s new identity as a patient
encouraged him to create an autobiographical narrative that justified his use
of pain meds.
Autobiographical narratives are the stories we tell about our lives, and
they are as fundamental to human existence as breathing. Our life stories
connect us to others, organize experience, and shape time. Autobiographical
narratives are deeply influenced by the prevailing culture—religious
affiliation, ethnic background, contemporaneous historical events. Culture
not only provides the frame of reference in which life narratives are told but
also influences the perception and memory of the experiences themselves.
Jerome Bruner, in an essay entitled “Life as Narrative,” says that “the
culturally shaped cognitive and linguistic processes that guide the self-
telling of life narratives achieve the power to structure perceptual
experience, to organize memory, to segment and purpose-build the very
‘events’ of a life. In the end, we become the autobiographical narratives by
which we ‘tell about’ our lives” (694).59 Culture shapes narrative, and
narrative shapes experience.
As a hospitalized patient in pain, Jim could experience the high of
morphine without the accompanying guilt and shame that had contaminated
his pleasure in drinking during the latter years of his alcohol addiction.
Jim’s new narrative was possible because of new cultural norms concerning
the nature and meaning of pain. Today, the experience of pain in any form is
fraught with danger, in large part because pain, so the thinking goes, puts
the individual at risk to experience future pain.

Pain Is Dangerous
For millennia, we have understood pain in our lives to serve at least two
useful functions. First, pain is a warning system: what to avoid and what
not. Second, pain is an opportunity for spiritual growth: “What doesn’t kill
you makes you stronger,” “After darkness comes the dawn,” etc. Today,
pain is little valued for these reasons. Instead, modern American culture
regards pain as anathema, to be avoided at all cost. This new way of looking
at pain arises from the belief that pain can cause permanent neurological
damage that lays the foundation for future pain. This new conception holds
true for both mental and physical pain, and it has been a major contributor
to the prescription drug epidemic.

Mental Pain as a Psychic Scar

Our culture is steeped in the idea that psychological trauma creates a
psychic wound that is the source of future suffering. The classic example of
this is post-traumatic stress disorder, which holds that any kind of trauma
can lead to future symptoms of anxiety, disturbing memories, abnormal
autonomic function, extreme and maladaptive avoidant behavior, and so on.
The Canadian philosopher Ian Hacking writes about the “traumatization of
experience, in other words, the conceptualization of the past event as a
painful scar.”60
The origin of this idea dates back at least to Freud, whose
groundbreaking psychoanalytic contribution (early 1900s) was the idea that
early childhood experiences can influence behavior in later life. Our
awareness of these early experiences and their impact on our emotions and
behaviors can occur outside of conscious awareness. Unconscious
childhood trauma is in turn the root of many forms of psychopathology. The
idea that an experience in one’s past can have a lasting psychological and
often unconscious effect on one’s behavior in the present is one that we
practically take for granted today, but it was a profoundly radical idea, one
that changed the way twentieth-century Western peoples understood their
lives.

Chronic Pain and Centralized Pain Syndromes

The role of physical pain has likewise undergone a similar transformation.
Two hundred years ago, physical pain was viewed by most physicians as a
desirable component of the healing process.61 Pain was believed to be
especially salutary during surgery, by invigorating cardiovascular function
and bolstering the immune response. By the mid-1850s, improved
treatments for pain, such as morphine and the hollow-needle syringe used to
administer it, invented by Alexander Wood in 1855, contributed to changing
views about treatment. With a viable alternative for treating pain, more
doctors began advocating for the use of opioid painkillers.61 By the 1950s,
pain as its own discipline was born within the medical profession, driven by
refined technology that allowed for opioids to be readily synthesized in the
laboratory and by an efficient pharmaceutical industry eager to sell them.
This new industry, more than any other factor, legitimized the treatment of
pain as a medical subspecialty unto itself, requiring its own training and
board certification.
Today, pain is considered an almost intolerable sensation for patients to
endure. Doctors are expected not just to lessen pain, but to eliminate it
altogether. The pressure to treat pain has become so overwhelming that
doctors who leave pain untreated are not just demonstrating poor clinical
skills; they are viewed as morally compromised. They are also legally liable
for malpractice.
The concept of pain as a long-term condition that can occur
independently of illness or injury is also very much a late-twentieth-century
phenomenon. Prior to 1900, pain was a response to acute illness or injury,
and there was as yet no concept of chronic (long-lasting) pain. It is now
commonly accepted within medicine that a patient can experience physical
pain that lasts months, even years, in the absence of any disease process or
recognizable physical injury. Indeed, the list of different types of chronic
pain syndrome seems to be growing every day, including complex regional
pain syndrome, failed back syndrome, fibromyalgia, interstitial cystitis,
myofascial pain syndrome, postvasectomy pain, vulvodynia, pelvic pain
syndrome—and on and on.
Today it is entirely commonplace to see a young, otherwise healthy
individual with no obvious injury or disease present to a medical doctor
seeking help for “corpedynia,” “corpe” for body and “dynia” for pain—full-
body pain. These patients describe experiencing pain from the tips of their
toes to the ends of their eyelashes. They undergo a full medical workup to
rule out recognizable causes of pain. Once those have been eliminated, the
patients are not carted off to the psychiatrist, as they might have been prior
to 1950. Instead they are given a variant diagnosis of “chronic pain,” such
as fibromyalgia.
As with psychological injury, physical pain, if not treated immediately,
is also believed to have the potential to contribute to future pain. This
phenomenon is known as “central sensitization,” and pain researchers talk
about “pain hypersensitivity . . . and secondary changes in brain activity
that can be detected by electrophysiological or imaging techniques.”62 Pain
researchers’ speculations that once the individual experiences pain, the
brain can be sensitized for future pain (making physical pain not just a
source of immediate suffering but also a potential source of future
suffering), created yet additional urgency to treat pain immediately and
completely.
We have arrived at a new, much lower threshold of tolerance for how
much pain is too much pain for an individual to suffer. Ironically, as our
lives have become progressively more comfortable, with modernization,
increased leisure time, and decreased threat of illness and injury, we have
become less and less able to tolerate any kind of pain. For patients seeking
treatment for physical and mental pain, these new norms have contributed
to increased prescribing and consumption of potentially addictive
prescription drugs.

Difference Is Psychopathology
Another contemporary illness narrative that has contributed to the
prescription drug epidemic, is one in which individual differences in
emotionality, cognition, and temperament are increasingly defined as
illness. When human differences are defined as illness, it naturally follows
that medical treatment is necessary to eliminate those differences. This idea
is fueled by our contemporary view of mental disorders, in which thoughts,
feelings, and actions are nothing more than neurons firing in a chemical
soup. Changing brain chemistry becomes the new way to normalize
differences.
The case of my patient Karen illustrates the ways in which identifying
and labeling innate differences as a form of brain pathology can lead, over
time, to medicating those differences with potentially addictive prescription
medications that can ultimately lead to addiction. Karen’s story is not meant
to suggest that every person who is diagnosed with mental illness and
treated with a scheduled drug has been misdiagnosed or will inevitably fall
prey to addiction. Indeed, some people are well served by giving their
innate differences a name and providing “treatment” in the form of
medication or otherwise. Karen’s story is merely a cautionary tale.
Born in the mid-1980s to loving, well-heeled parents, Karen was a
healthy, happy child, with no early signs or symptoms of illness, mental or
otherwise. Furthermore, her parents remember her as a kind and gregarious
child who excelled at sports. In elementary school, she made friends easily,
and with her prowess at ball sports and her easygoing nature, she was a
leader on the playground. However, she demonstrated difficulty with
reading comprehension and memory tasks compared to her peers. The
school psychologist diagnosed her with a nonspecific “learning disability.”
Once the diagnosis had been made, Karen’s parents and the school
mobilized to provide Karen with additional support to overcome her
disability. She got help from tutors, education experts and psychologists,
and with their support, her reading improved.
 In middle school Karen continued to struggle with academics, but on
the basketball court, her ability to learn was intact. In high school she
became a top basketball player and was recruited by several colleges to play
at the collegiate level. She decided to forgo playing basketball in college,
however, to focus on academics, consistent with the more conservative
traditions of her family. Karen arrived at college in 2005 with high
expectations but without the support structure she was used to. The classes
were huge, the material more challenging, and she had no more tutors to
help her. She was faced with unprecedented amounts of free time that she
wasn’t sure how to organize. She struggled to work efficiently, and reading
was still a chore.
Despite these early challenges, Karen was able to do moderately well in
her college classes in her first couple of years. But she was ambitious, and
in her junior year she decided to major in both art history and graphic
design. She was required to increase the number of classes she was taking
and with the added pressure, was quickly overwhelmed. She saw some of
her peers taking more classes and doing well, and she wondered why she
couldn’t do the same.
Two of Karen’s best friends had been diagnosed with attention deficit
disorder (ADD)—similar to attention deficit hyperactivity disorder
(ADHD) but without the high energy component—and were taking
stimulant medication (for example, Adderall or Ritalin). Karen wondered if
ADD might be a possible explanation for her inability to excel with the
increased course load. She decided to see a doctor and get tested.
She met with a psychiatrist, answered a series of questions dating back
to childhood—questions on her ability to concentrate, sit still, get
organized, accomplish tasks. Based on one visit, the doctor diagnosed ADD
and wrote Karen a prescription for Adderall extended release (XR)
formulation 15 mg daily, as well as Adderall immediate release (IR) 10 mg
daily.
Adderall is an FDA schedule II drug, which means that, although it has
been shown to have medical benefit, it also has a high potential for misuse
and addiction. It is molecularly similar to the street drug methamphetamine,
also known as “ice” or “crank.” Adderall has been used for decades as a
performance enhancing drug in the military, but not until the 1980s was it
common practice to prescribe Adderall and other stimulants for the
treatment of attention deficit disorder, including prescribing it to children
and adolescents. The total numbers of prescriptions for stimulants dispensed
by US pharmacies between 1991 and 2010 increased tenfold.63
Prescriptions for stimulants among school age children (5–18 years) nearly
tripled between 1990 and 1995 alone.64
When Karen took Adderall, she could sit in a chair for hours at a time,
at home or at the library, studying, and she retained the material better. She
understood her response as validation of her diagnosis of ADD. This kind of
backward logic prevails in the mental health care field: if the medicine
makes you feel better, then your diagnosis must be whatever the medicine
was meant to treat. We know, however, that stimulants will make almost
anyone better able to focus, concentrate, and perform certain types of tasks,
even in the absence of a cognitive disorder. Likewise, benzodiazepines
(Xanax) help people relax in the absence of anxiety, sedatives (Ambien)
induce sleep in the absence of insomnia, and opioids (Vicodin) enhance
subjective well-being in the absence of pain.
We are all born with inherent mental and physical differences. What is
striking in our culture today is how readily those differences are labeled as
illness and treated with a pill. From early childhood onward, Karen’s
learning differences were framed as brain pathology. Her relative lack of
aptitude for reading was called a learning disability, and her struggles in
college diagnosed as attention deficit disorder. This is not to invalidate
Karen’s relative difficulties with reading or other academic pursuits. But in
embracing these differences as “disabilities” or “disorders,” our culture is
implicitly rejecting alternative narratives, for example, that human
differences in temperament and ability are valuable and should be
celebrated and that human differences should be understood in terms of
sociological, existential, and even spiritual etiologies, rather than purely
biological ones.
An experienced psychologist who treats college and graduate students at
a university student mental health clinic described it this way: “What I
frequently see in my 20- to 30-something patients is they come to therapy
self-identifying with mental health disorders that were diagnosed in
adolescence. They take meds and are fearful that the stress of their lives will
trigger their ‘illness.’ Almost always the flares of ‘illness’ are triggered by
difficult life events, but the go-to intervention that they always turn to is an
adjustment to the medication.”
 In The Myth of Mental Illness, Thomas Szasz famously declared that
mental illness does not exist because there are no specific anatomical or
molecular markers that define it.65 Mental illness, according to Szasz, is
merely a means by which “the therapeutic state” exerts social control on its
citizens, for example, by enforced temporary hospitalization of the mentally
ill. I do not agree with Szasz that mental illness does not exist; the absence
of biological markers is not the absence of disease. As Clarke describes in a
critique of Szasz,66 for many years we did not know what caused malaria,
until certain advances in molecular science made its discovery possible. Yet
we knew the disease of malaria when we saw it. Likewise the patient with
schizophrenia, psychotic mania, severe obsessive compulsive disorder, etc.,
is struggling with a brain disease, even if we can’t necessarily measure it or
see it under a microscope. But Szasz’s point that we risk coercing
conformity by labeling all deviant behavior as mental illness is relevant
here. A prime historical example is homosexuality, which was considered a
mental illness as recently 1973.67
Today, our definition of mental illness subsumes not only deviancy but
even subtle differences between us. It has become a way to understand not
only failure to conform but also failure to excel. Now even the average
underachiever and the quirky recluse risk a diagnosis of mental illness. For
some individuals, receiving a diagnosis of a mental illness is no doubt
helpful, giving them access to resources they might otherwise not have had
and providing them with a framework to understand their differences,
without which they might have felt stigmatized and ashamed. What
concerns me is the leap between diagnosing differences and treating
differences with a pill, especially when that pill carries with it the risk of
addiction.
Doctors are of course complicit in this process, particularly
psychiatrists, who over the last thirty years have increasingly turned to
psychoactive drugs to manage their patients’ emotional distress, psychiatric
symptoms, or life crises, leaving the business of psychotherapy to others.68
Why have psychiatrists largely abandoned their roots in psychoanalysis and
other forms of talk therapy in favor of the magic of the pill? They have
done so in part because they have become true believers in the
reductionistic, biologized view of human behavior (neurons firing in a
chemical soup). Financial incentives for doctors to prescribe pills have also
contributed to this trend (see chapter 8).
This paradigm shift has created an entire generation of young people,
most notably the millennials (1980–2000), who have embraced the promise
of better living through chemistry. From 1998 to 2008, the percentage of
Americans who took at least one prescription drug in the past month
increased from 44 percent to 48 percent. The use of two or more drugs
increased from 25 percent to 31 percent. The use of five or more drugs
increased from 6 percent to 11 percent. In 2007, one of every five American
children and nine out of ten older Americans (age 60 and older) reported
using at least one prescription drug in the past month. The most commonly
used types of drug are central nervous system stimulants for adolescents
and antidepressants for middle-aged adults. In the United States, spending
for prescription drugs was $234.1 billion in 2008, more than double the
amount spent in 1999.69
Many of today’s youth think nothing of taking Adderall (a stimulant) in
the mornings to get themselves going, Vicodin (an opioid painkiller) after
lunch to treat a sport’s injury, “medical” marijuana in the evening to relax,
and Xanax (a benzodiazepine) at night to put themselves to sleep, all
prescribed by a doctor. Getting the equivalent of those prescriptions from a
friend, a family member, or even a drug dealer is not a very big stretch.
Twenty-six percent of today’s teens believe that prescription drugs are a
good study aid.70 Two-thirds of college seniors will be offered prescription
stimulants for nonmedical use, and 31 percent will use a prescription
stimulant for nonmedical use at least once during their college career.71 The
number of cases of prescription stimulant intoxication or misuse in
adolescents rose 76 percent between 1998 and 2005.72 Prescription drugs
are now the second most-misused category of drug among adolescents,
behind only marijuana.73
My young patients have candidly asked me, “What really is the
difference between a medication you prescribe, and a drug I get from a
friend or buy on the street to do the same thing?” I have responded with
complex justifications involving legality and safety. But the real answer is,
not very much. Sadly, the unintended consequence of being weaned on
pharmaceuticals is a vicious and unprecedented scourge of addiction.
 From Medicating an Illness to Feeding an
Addiction
Karen began staying up late into the night doing work and was so
productive with the Adderall that she was reluctant to waste her time
sleeping when she could get so much done. She often didn’t get to sleep till
two in the morning. She stayed in on weekends to work on school projects,
forgoing social activities with friends. Soon, nothing was as rewarding as
working, and although her friends expressed dismay at her increasing
reclusiveness, Karen was celebrated by her teachers for her productivity.
After graduating from college in 2009, Karen went to design school.
Her dream was to be an interior decorator. She found a New York
psychiatrist on Google who advertised expertise in treating ADD. Karen
went to the doctor, paid for the visit in cash, and got a prescription for
Adderall XR 20 mg daily and Adderall IR 20 mg daily. The psychiatrist did
not ask for collateral information or prior records to verify diagnosis or
dose. The session lasted less than fifteen minutes.
Furthermore, her new psychiatrist told her that Adderall IR could be
taken on an “as needed” basis, that is to say, “whenever you’re having
symptoms.” With this advice, Karen began taking the medication not only
when she was having trouble studying or working but increasingly when
she struggled with any kind of negative emotion—anxiety, sadness,
frustration, boredom. The medicine lifted her mood and improved her
energy—proof, she reasoned, that ADD was the cause of her distress.
Over the next two years, seeing the same doctor, Karen’s dose gradually
increased to Adderall XR 25 mg daily and Adderall IR 20 mg twice a day,
more than double what she had started on in college. Her visits with the
doctor were very short, sometimes no more than ten minutes. Karen never
said much, except to emphasize how well she was doing and how much the
Adderall was helping her function in the world.
However, Karen now reflects that, despite telling others she was
thriving, in reality her life was beginning to fall apart. She was sleeping
little, spending all her time working, barely seeing her friends, and no
longer dating at all. She failed to show up for meetings and classes, always
canceling at the last minute. She developed overwhelming anxiety in social
situations, which she had never had before. She spent more and more time
alone, in her apartment, nominally “doing work.”
“Doing work became my excuse for doing Adderall. I had to be
successful, and I needed the Adderall to do the work, not realizing I did
better work when I didn’t take the Adderall.”
Studies show that stimulants like Adderall enhance memory and
attention, but there is little or no research on their effects on abstract
thought or creativity.74 Indeed, there may be a trade-off between the ability
to have laser focus to complete a specific task and the ability to let the mind
wander, make new connections, and create something new.
Hanif Kureishi, writing in the New York Times in an essay called “The
Art of Distraction,” reflects:

Sometimes things get done better when you’re doing something else. If you’re writing and you
get stuck, and you then make tea, while waiting for the kettle to boil the chances are good ideas
will occur to you. Seeing that a sentence has to have a particular shape can’t be forced; you have
to wait for your own judgment to inform you, and it usually does, in time. Some interruptions are
worth having if they create a space for something to work in the fertile unconscious. Indeed,
some distractions are more than useful; they might be more like realizations and can be as
informative and multilayered as dreams. They might be where the excitement is.75

In early 2011, Karen’s psychiatrist was out of town when Karen needed
a refill. Desperate for her medications, she found a self-advertised “ADD
psychiatrist” on Google and went to see him. Karen knew what to say. It
was easy to get this doctor to write her another prescription. Karen now had
two psychiatrists filling the same prescription.
“I didn’t feel I was doing anything wrong—getting the same
prescription from two different doctors—which is really weird looking back
on it. I told myself I needed the medication for an illness. I needed it to
survive. But the truth was, I had started putting the drug above food and
sleep and my own ethics.”
In July 2011 Karen moved back to California to live with her parents
and look for a job. The next three years of Karen’s life were filled with lots
of doctors, lots of Adderall prescriptions, and lots of juggling doctors to get
those prescriptions. Her standard reported dosage to any doctor she visited
was now Adderall XR 50 mg daily (Physician’s Desk Reference maximum
daily dose of Adderall XR is 20 mg), plus Adderall IR 20 mg twice daily.
When a doctor balked at prescribing that much, Karen always agreed to
start at a lower dose and then cajoled them into prescribing higher doses
over time. For her the key to getting her doctors to increase the dose over
time was to emphasize how functional she was with the medication, how
nonfunctional without it, and how much she appreciated their help, none of
which, from her perspective, was a lie. By now her evolving illness
narrative had legs. That she was getting multiple prescriptions from
multiple doctors and lying to them about lost prescriptions and lost bottles
to get more of the drug represented a minor wrinkle in the larger fabric of
the story she and her doctors had woven together over time: she had an
illness, namely, ADD, and the Adderall was effective treatment for that
illness.
By 2013, Karen had three different doctors prescribing Adderall at the
same time, for a minimum daily consumption of Adderall XR 150 mg and
Adderall IR 120 mg daily. Karen began stealing money from her parents
because her insurance would only cover one prescription per month. She
needed on average $1,200 per month just to be able to afford her
prescriptions. She lied to her parents about where the money had gone
—“toiletries and cosmetics”—and they believed her. In January 2014 she
stole her father’s credit cards and charged $25,000 to an online site on home
décor items for her apartment. She also got a speeding ticket. Both of these
behaviors she now attributes to compulsive Adderall use, but her parents
interpreted her behavior as a money-management issue, and they insisted
she get professional help for that problem. Neither imagined that behind the
stealing, speeding, and spending was an Adderall addiction.
The therapist she went to see for help with her personal finance habits
discovered the Adderall addiction by using the prescription drug–
monitoring database and uncovering multiple identical prescriptions from
multiple doctors. This was not the first time one of her doctors had
discovered her secret. When it had happened once before, the psychiatrist
had refused to treat her, and so Karen moved on to another one. This time,
the psychiatrist asked Karen’s permission to inform her parents. Karen
reluctantly agreed.

Enduring Pain Instead of Medicating It Away

Karen came to see me as the result of an ultimatum from her parents and
her psychiatrist: get an evaluation by an addiction medicine doctor, or else.
At first Karen wanted to talk only about her attention deficit disorder and to
explain away her Adderall use as a necessary accommodation of her illness.
I said, as I usually do in this kind of situation, that whatever compelled her
to first start using the drug, even if it was a legitimate medical indication,
had now escalated to the level of an addiction, and if we didn’t target and
treat the addiction, her underlying disorder would not improve either.76 We
slowly tapered her down and off of Adderall, and she attended a day-
treatment program for addiction, consisting of groups, psychoeducation,
and skills training related to the treatment of addiction.
Karen has been abstinent from stimulants for almost a year. Stopping
Adderall hasn’t been easy for her. The biggest challenge has been rewriting
her personal narrative. She has had to learn to live in the world without
medicating away her limitations. She has had to tolerate normal ebbs and
flows of energy, subjective well-being, and creativity. She has had to accept
that sometimes when she is feeling down or tired, bored or angry, sad or
inattentive, she can’t willfully erase those feelings. She just has to endure
them.
 4

Big Pharma Joins Big Medicine

Co-opting Medical Science to Promote Pill-Taking

Jim lay flat on his back in a hospital bed, morphine seeping into his veins
through a long, thin, transparent tube. He felt no pain of any kind, and yet
he continued to be obsessively preoccupied with his next dose of pain
medication. As the time approached, he counted the minutes and seconds
until he could ring the nurse and ask for more. She wouldn’t just give it for
free, however; he had to answer her questions the right way. She would
always ask the same question before she could administer the meds: “On a
scale from 1 to 10, how bad is your pain, with 0 being no pain, and 10 being
the worst pain you could possibly imagine.”
After years of manipulating people to manage, or attempt to manage, his
drinking, Jim had developed a deep understanding of certain aspects of
human psychology, especially how to appear trustworthy while lying. In
this instance, he applied those skills, because he was not in fact having
much if any pain by day three into his hospitalization. But he wanted those
opioids.
He figured that if he said “10,” he would be seen as someone who
exaggerated. If he said anything less than “7,” he might not get his
morphine, which he already thought of as his. So he said, “My pain is real
bad, it’s a 7,” going for the middle of the road approach as a way to appear
reasonable but still sufficiently distressed. Whether due to Jim’s skillful
psychological manipulation or not, “7” worked every time, and Jim
managed to get intravenous morphine every four hours continuously for his
entire hospital stay, which lasted about a week.
There was only one moment when Jim suspected that he was in trouble.
It was a conversation with one of his nurses.
 “Jim,” said the nurse, “You’re taking a lot of this stuff, and I’m worried.
I’ve seen so many people come through here and end up sicker than when
they started because of these pain meds. They get hooked. I don’t want that
to happen to you. So if you could cut back, that would be good. But if you
tell me you’re in pain,” she added, as if catching herself, “I’ll give it to you
every time.”
Very quiet and distant alarm bells rang in Jim’s brain, but they were too
quiet and too distant to compete with his overwhelming craving for the next
dose of morphine.
“I can handle it,” he told her, “and I’m in pain.”
This interaction between Jim and his nurse is crucial to understanding
the rapid rise in prescription opioid addiction and opioid-related deaths.
Jim’s nurse knew on some level that Jim was getting too many opioids, and
she even admitted to seeing patients “end up sicker than when they started”
because of the amount of opioids they received while hospitalized. But
despite her misgivings, she felt pressure to follow the standardized protocol:
no cumulative dose or duration of opioids is too high for a patient still
endorsing pain.

Curing Doctors of Their “Opioiphobia”

The prolific opioid prescribing that characterized the 1990s and 2000s and
that continues today, at a galloping although somewhat slower pace,
represents a radical shift in practice. Prior to 1980, doctors used opioid pain
relievers sparingly, and only for the short term in cases of severe injury or
illness, or during surgery.77, 78 Their reluctance to use opioids for an
extended length of time, despite their short-term effectiveness for pain,
sprang from fear of causing addiction.*
In the early 1980s, however, professional medical opinion on the use of
opioid pain relievers began to change, in favor of using opioids more
liberally. The number of patients living with pain was growing, due to an
aging population, to more people undergoing and surviving complicated
surgeries, and to more people being kept alive with life-threatening
illnesses. A new movement, known as hospice care, was beginning to make
inroads in the United States at this time as well, advocating for more
aggressive comfort care at the end of life.
What began as a good faith effort to improve the lives of patients in pain
soon gave way to an epidemic of opioid painkiller overprescribing. The
pharmaceutical industry (Big Pharma), specifically the makers of opioid
painkillers like OxyContin (Purdue Pharma), played a pivotal role in the
epidemic. 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 Food and Drug Administration. Together, these
different factions manipulated and misrepresented, deliberately or
otherwise, medical science to serve their own agendas.

The Role of Academic Physicians

It had been common practice before 2000 for doctors to accept gifts, meals,
payments, travel, and other services from companies that made the drugs
and medical products they might recommend to their patients.*79 Many of
these overt attempts to influence doctors have since been banned by
hospitals and other health care institutions across the country, in recognition
that even a free pen and half an hour of a drug representative’s time can
unduly influence prescribing practices. An analysis published by the
Journal of the American Medical Association found that doctors who accept
perks from drugmakers are more likely to prescribe that drugmaker’s brand
of drugs.80 Recent federal legislation demands that doctors who receive
financial reimbursement from a drug or medical supply company disclose
those payments. In September 2014, the Sunshine Act required that all
corporate payments to physicians worth $10 or more be published in an
online database, in hopes that more transparency would alert patients to
which doctors might be unduly influenced by industry.79 These changes
discouraged many doctors from openly taking gifts from Big Pharma.
Big Pharma responded by changing tactics. Instead of influencing
doctor-prescribing by giving perks directly to doctors, it instead enlisted the
help of academic researchers to promote its products, while itself remaining
invisible, in the background. Big Pharma dubbed these doctors “thought
leaders,” choosing only researchers whose results favored their drug. They
paid for thought leaders to travel across the country presenting their work at
medical conferences and so-called informational seminars. Pharmaceutical
companies were careful not to overtly associate their thought leader’s
message with their brand. They often paid thought leaders large sums of
money to speak, and in some instances provided the funds to subsidize the
entire medical conference/seminar. They promoted the drug company’s
product, while also furthering their elected thought leader’s academic
career.
This insidious yet incredibly powerful method—what amounts to a
Trojan Horse of drug peddling—represents a betrayal of the average doctor
seeing patients. The average clinician relies on his or her academic
colleagues to present unbiased research. When the average doctor attends
an academic conference, he or she trusts that the organizers of the
conference will feature speakers who represent diverse and scientifically
valid viewpoints.
New York Times journalist Barry Meier, in his excellent book Pain
Killer,81 describes how Big Pharma chose Dr. Russell Portenoy as their
“thought leader,” supporting his travel around the country to promote more
liberal opioid prescribing for many types of pain. Dr. Portenoy’s talks were
sponsored by drug companies or by the Dannemiller Foundation, an
organization paid by drug companies to put on continuing medical
education programs for doctors. Dr. Portenoy had financial relationships
with at least a dozen companies, most of which produced prescription
opioids.81
The first misconception about opioid painkillers conveyed to doctors by
Dr. Portenoy and others is that these drugs are effective for the treatment of
chronic pain (pain lasting three or more months). The benefit of short-term
opioid therapy is supported by multiple clinical trials,82 but there is very
little evidence to support the use of opioids for managing chronic pain, and
the risks of long-term use may outweigh the benefits.83 One of the risks,
paradoxically, may be an increase in pain due to a phenomenon called
“opioid induced hyperalgesia” (OIH), “hyper” for “more/over,” and
“algesia” for “pain.” Animal and human studies show that prolonged use of
opioid painkillers can cause heightened sensitivity to pain and result in pain
syndromes that did not previously exist.84 One small prospective study of
six patients with chronic lower back pain started on oral morphine
demonstrated that all six developed hyperalgesia (increased sensitivity to
pain) after four weeks.85
The second misconception is that no dose of opioid painkillers is too
high for the treatment of pain. In fact, we know that tolerance to the pain-
relieving effects of opioids occurs in most individuals after weeks to
months, at which point the opioids stop working, no matter how high the
dose. The risk of side effects, however, rises in a dose-depending manner83
—the higher the dose, the worse the side effects, including the risks of
addiction and death due to accidental overdose.
Dr. Portenoy based his false assertions on a study he had published in
1986 with Dr. Kathleen Foley in a medical journal simply called Pain. The
study was a review of thirty-eight patients with chronic pain treated with
opioid painkillers. Portenoy and Foley wrote that “opioid maintenance
therapy can be a safe, salutary and more humane alternative . . . in those
patients with intractable non-malignant pain and no history of drug
abuse.”86 This statement represents a plea for a departure from previous
practice, in which opioids were used almost exclusively for acute (after
surgery or injury) and palliative (at the end of life) pain. The authors also go
on to say that no amount of opioids to treat chronic pain is too much, again
flying in the face of convention, which had always advocated using the bare
minimum to avoid the risks of death due to respiratory suppression and
addiction: “We disagree with the concept of setting a maximum dose. The
pharmacology of opioid use in the treatment of pain is based on dose
titration to effect.”86
Portenoy and Foley’s review of thirty-eight patients does not, however,
constitute a high level of scientific evidence. It did not include a large
number of patients. There was no comparison group taking a placebo or
getting some other treatment for pain, such as physical therapy. It was
retrospective rather than prospective, meaning that the authors asked
patients to recollect past experiences, biased by recall effects, rather than
soliciting their reactions going forward in real time. Although these patients
endorsed improvements in pain with opioids, they did not report any
functional improvement. Yet this study became very well known in the
medical community, and its publication and dissemination correlated with a
sudden uptick in the rate of opioid prescriptions for patients with chronic
pain.87
As Portenoy’s talks drew ever larger crowds, he frequently referenced
other publications that supported his view.81 He invoked a 1980 New
England Journal of Medicine letter to the editor entitled “Addiction Rare in
Patients Treated with Narcotics.” The letter reported that among
hospitalized patients taking opioids for pain, clinical researchers had found
“only four cases of addiction among 11,882 patients treated with opioids.”46
This letter was widely cited by doctors and medical organizations and
frequently quoted by the pharmaceutical industry in its advertisements for
opioids, as proving that “less-than-1%” of patients receiving opioids for
pain become addicted.81 This misconception—that as long as doctors were
prescribing opioids for the treatment of pain, there was less than a 1 percent
chance of their patients becoming addicted—was perhaps the most
egregious. It implied that the well-known inherent addictive potential of
opioids was magically eliminated by the halo of a doctor’s prescription. We
know now that opioid painkillers prescribed by a doctor are as addictive as
heroin purchased on a street corner.
The final misconception perpetuated by the pseudoscience of this era
was the idea of “pseudoaddiction.” Based on a single case report of a
patient who engaged in drug-seeking behavior due to inadequate pain
control,88 doctors were taught that any patient prescribed opioid painkillers
who demonstrates drug-seeking behavior is not addicted, but in pain. The
solution? Increase the dose of opioid painkillers. We know that many
patients have severe debilitating pain, and sometimes the appropriate
intervention is to increase the opioid painkillers. But some patients who
report pain and are engaging in drug-seeking behavior are addicted to
opioids. They may also have untreated pain. To help this population,
doctors need to recognize and treat both disorders, not ignore the possibility
of addiction.
In a taped interview with Dr. Russell Portenoy in 2011, on the website
for the advocacy group Physicians for Responsible Opioid Prescribing
(PROP),89 Portenoy describes his unabashed advocacy for opioids in the
1990s and early 2000s as follows: “I gave so many lectures to primary care
audiences in which the Porter and Jick article46 was just one piece of data
that I would then cite. I would cite 6 to 7 maybe 10 different avenues of
thought or evidence, none of which represents real evidence. And yet what I
was trying to do was to create a narrative so that the primary care audience
would look at this information in toto and feel more comfortable about
opioids in a way they hadn’t before. . . . Because the primary goal was to
de-stigmatize, we often left evidence behind.”89

The Role of Professional Medical Societies

Every medical specialty, from family medicine to orthopedic surgery, has
medical societies created by and for the doctors who practice it. The
purpose of a medical society is to promote the specialty and its doctors and
also, theoretically, to advocate for patients.
Beginning in the 1980s, pain societies campaigned for better treatment
of patients with pain, including arguing for more liberal use of opioid
painkillers in the treatment of pain. On the face of it, their intentions were
noble. But closer scrutiny reveals that some of these pain societies were
financially subsidized by drug manufacturers and as such were biased. They
helped propagate data that turned out to be untrue, including minimizing the
risk of addiction to opioid painkillers prescribed for pain and inflating the
number of Americans struggling with pain. They also influenced the
creation of a new stigmatized identity: the doctor unwilling to prescribe
opioids for patients in pain.
The American Pain Foundation, a medical society for doctors who treat
pain, received 90 percent of its $5 million funding in 2010 from the drug
and medical device industry. The extent to which other pain societies might
have been subsidized by Big Pharma is unclear, but according to an article
published in ProPublica in 2012, US senators Baucus and Grassley
launched an investigation into the American Pain Foundation, the American
Academy of Pain Medicine, the American Pain Society, the Wisconsin Pain
and Policy Group, and the Center for Practical Bioethics, exploring the
extent to which drug manufacturers such as Purdue Pharma, Endo
Pharmaceuticals, and Johnson and Johnson might have encouraged these
societies to promote opioid painkiller prescribing.90
The American Pain Society, founded in 1995 with Dr. Portenoy as its
first president, issued treatment guidelines urging doctors to prescribe more
opioids for the treatment of pain. Their self-proclaimed goal was to cure the
medical community of its “opioiphobia” (fear of prescribing opioids). The
American Pain Society and the American Academy of Pain Medicine
published a consensus statement in 1997 which proclaimed there was
insufficient evidence to conclude that opioids, when prescribed for the
treatment of pain, can result in opioid addiction.91
In 2011, the Institute of Medicine (IOM) committee, commissioned by
the US Congress, issued a report called “Relieving Pain in America.” In it,
they declared that 100 million Americans—nearly a third of the population
—suffer from chronic debilitating pain, at a cost of $600 billion a year in
medical treatments and lost productivity.92 They also claimed that a
“cultural transformation” was necessary to improve pain management.
However, the number 100 million was an exaggeration, the real number
being closer to 25 million Americans with debilitating pain, or
approximately 15 percent of the population.93 Twenty-five million is still a
high number of individuals in pain, and these patients need and deserve
medical attention. But the cultural transformation the IOM report demanded
had already occurred, to the point that doctors were engaging in excessive
opioid prescribing.
In 2010 the International Association for the Study of Pain (IASP)
issued a declaration stating that all patients are entitled to “access to pain
management without discrimination . . . on the basis of age, sex, gender,
medical diagnosis, race or ethnicity, religion, culture, marital, civil, or
socioeconomic status, sexual orientation, and political or other opinions”;
and “appropriate treatment includes access to pain medications, including
opioids and other essential medications for pain.”94 This statement reads
more like a patient bill of rights than a policy guideline, illustrating how the
campaign to destigmatize the use of opioid therapy turned into a campaign
to stigmatize any doctor who wasn’t prescribing opioids for pain. Opioids,
doctors were told, needed to be prescribed for all forms of pain, at ever-
increasing doses, lest the doctors risk engaging in unethical, discriminatory
practices.

The Role of the Federation of State Medical

Boards
The Federation of State Medical Boards (FSMB) is a national organization
that oversees the seventy medical and osteopathic boards of the United
States and its territories. The state board organizations serve many
functions, one of which is to police doctors and exert disciplinary action
against doctors who are deemed dangerous to patients. One of the most
severe forms of disciplinary action is to revoke a doctor’s license to practice
medicine.
In 1998, the FSMB issued a policy to reassure doctors that they would
not be prosecuted if they prescribed even large amounts of opioids, as long
as it was for the treatment of pain. In 2001, every licensed physician in the
state of California was mandated to attend a day-long course on the
treatment of pain as a requirement to maintain licensure. The federation
urged state medical boards to punish doctors for undertreating pain. Doctors
lived in fear of disciplinary action from the board, and the lawsuit that
usually followed, if they denied a patient opioid painkillers. In 1991 in
North Carolina, in the case of Henry James v. Hillhaven, $7.5 million was
granted to the family because a nurse did not follow the doctor’s order to
properly address pain. In 1998 in California in the case of Bergman v. Eden
Medical Center, $1.5 million was granted to the family because the
physician did not properly address the patient’s pain.
The FSMB published a book promoting the use of opioid painkillers.
This book was funded by Purdue Pharma, Endo Health Solutions, and
others, with proceeds totaling $280,000, and was developed with the help of
David Haddox, a senior Purdue Pharma executive.81 The federation
admitted to receiving nearly $2 million dollars from opioid makers since
1997 to support its efforts.81

The Role of the Joint Commission on

Accreditation of Healthcare Organizations
The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO), often simply referred to as “The Joint Commission” (TJC), is a
United States–based nonprofit tax-exempt 501(c) organization that accredits
health care organizations and programs in the United States. The Joint
Commission arose out of a movement in the 1950s to reform hospitals by
looking at whether or not patients got better. JCAHO went through a
consolidation of power over the years, combining multiple medical
organizations under one roof, simplifying its name in 2007 to “The Joint
Commission.” Its mission statement is “Helping Health Care Organizations
Help Patients.”
Today, having Joint Commission accreditation is required for many
hospitals and clinics to remain licensed. Payment for services from the
Centers for Medicare and Medicaid Services (CMS), the largest federally
funded insurance program, is also contingent on TJC approval. TJC
approval is obtained through periodic surveys. Huge amounts of time and
large sums of money are devoted to preparing for these surveys, which
hospitals must pay TJC to perform.
These surveys assess adherence to “best practices.” Best practices are
defined by TJC itself: “Joint Commission standards are developed with
input from health care professionals, providers, subject matter experts,
consumers, government agencies (including the Centers for Medicare &
Medicaid Services) and employers. They are informed by scientific
literature and expert consensus and reviewed by the Board of
Commissioners. New standards are added only if they relate to patient
safety or quality of care, have a positive impact on health outcomes, meet or
surpass law and regulation, and can be accurately and readily measured.”95
In 2001, The Joint Commission made “pain” the fifth vital sign,
alongside heart rate, temperature, respiratory rate, and blood pressure,
indicating the state of a patient’s essential body functions. Pain, however,
unlike the original vital signs, cannot be objectively measured. Thus, TJC
promoted the use of the Visual Analog Scale of pain assessment (a series of
happy and sad faces corresponding to degrees of pain), accompanied by a
number on a scale from 1 to 10, with 10 out of 10 pain being the worst pain
a human being could endure and 1 the pain equivalent of, let’s say, a
stubbed toe. Quantifying pain made it possible to standardize procedures
across doctors and met TJC’s own requirement of implementing new
standards only if they could “be accurately and readily measured.”
Despite the appearance of objectivity, the Visual Analog Scale and the
numerical pain scale represent entirely arbitrary measurements. There is in
fact no way to measure a person’s pain. One person’s severed leg might be a
1 on the pain scale, and another person’s stubbed toe a 10. Furthermore, no
scientific studies show that using these pain scales correlates with improved
patient outcomes. Data do show, however, that use of these pain scores
increases opioid prescribing and opioid use.96, 97
The Joint Commission launched a nationwide “pain management
educational program.” They sold educational materials to hospitals so they
could meet the standards of pain treatment that would be required to pass
the next Joint Commission Survey.98 These materials included laminated
cards and posters of the Visual Analog Scale of pain, as well as teaching
videos promoting more liberal prescribing of opioids for pain: “Some
clinicians have inaccurate and exaggerated concerns about addiction,
tolerance and risk of death. . . . This attitude prevails despite the fact there is
no evidence that addiction is a significant issue when persons are given
opioids for pain control.”99 Many of these teaching materials were
produced by Purdue Pharma, the makers of OxyContin, and given to TJC,
free of charge.
A Government Accountability Report, published in 2003, had this to say
about the relationship between TJC (herein referred to as JCAHO) and
Purdue Pharma:

From 1996, when OxyContin was introduced to the market, to July 2002, Purdue has funded over
20,000 pain-related educational programs through direct sponsorship or financial grants. These
grants included support for programs to provide physicians with opportunities to earn required
continuing medical education credits, such as grand round presentations at hospitals and medical
education seminars at state and local medical conferences. During 2001 and 2002, Purdue funded
a series of nine programs throughout the country to educate hospital physicians and staff on how
to comply with JCAHO’s pain standards for hospitals and to discuss postoperative pain
treatment. Purdue was one of only two drug companies that provided funding for JCAHO’s pain
management educational programs. Under an agreement with JCAHO, Purdue was the only drug
company allowed to distribute certain educational videos and a book about pain management;
these materials were also available for purchase from JCAHO’s Web site. Purdue’s participation
in these activities with JCAHO may have facilitated its access to hospitals to promote
OxyContin.98

In 2012, The Joint Commission published a report on the safe use of

opioids in hospitals, publicly recognizing the need for improved patient
assessment and management to lower the incidence of opioid overdose in
the inpatient setting.100

The Role of the Food and Drug Administration

The Food and Drug Administration (FDA) is an agency within the US
Department of Health and Human Services responsible for assuring the
safety, effectiveness, and quality of medical drugs. They are responsible for
approving drugs before they reach the market and monitoring the safety and
marketing of those drugs once they have become available to the public.
The FDA contributed to the prescription opioid painkiller epidemic by
failing to prevent drug companies from promoting opioid painkillers in the
treatment of chronic pain, for which there was little evidence, and by
making it easier for pharmaceutical companies to get FDA approval for new
opioids coming on the market.
Every pharmaceutical company that seeks FDA approval for a particular
drug must demonstrate to the FDA in a series of clinical trials (studies) that
their drug is better than a placebo (a sugar pill) and that, whatever side
effects posed by the drug, the potential benefits (for a given population of
patients) outweigh the risks. In the late 1990s, the FDA implemented a new
study protocol for FDA approval called “enriched enrollment,” which it said
would result in smaller studies, shortened drug development time, and
lower development costs for the pharmaceutical industry. The investigative
journalist John Fauber, writing for the Wisconsin Sentinel, said the decision
to change study requirements arose from a series of meetings over more
than a decade between experts in pain medicine, primarily from academia,
and representatives of the FDA. The invitation-only meetings were
sponsored by Big Pharma, which paid up to $35,000 for drug company
representatives to attend, raising “serious questions about the way in which
federal regulators interact with the pharmaceutical companies they
regulate.”101 The enriched enrollment protocol does appear to be a way for
drug companies to cheat, getting approval for opioid painkillers that don’t
really work.
In traditional studies that assess the benefit of a drug as compared with a
placebo, participants are randomly assigned to participate in one group or
the other. The random assignment of the participants is fundamental to good
clinical studies because it insures that neither group is predisposed to do
better, or worse, on the drug or placebo, than the other. With this traditional
design, opioid medications in the treatment of chronic pain were not
performing well. This was happening for a number of reasons. First, a lot of
patients on opioids were dropping out of the study due to side effects, such
as dizziness, constipation, nausea, or vomiting. Second, participants in the
placebo group were doing better, in part because they weren’t having the
side effects. Placebo, it turns out, is pretty good medication for chronic
pain. Drug companies were understandably frustrated because they were
not getting the results necessary for FDA approval. So the study design was
revised. The new design, which persists today, is called “enriched
enrollment.”
With enriched enrollment, instead of giving half of the participants the
study drug and half the placebo, investigators give everyone the study drug
in what is called the “open-label phase,” because both researchers and
participants can see the metaphorical label on the pill bottle and know the
subject is getting an opioid. During this open-label phase, as many as half
of the participants typically drop out due to side effects and opioid
intolerance, or maybe just because opioids are not a good medicine for
chronic pain. The people left in the study are all the people who are on
some level benefitting from the opioids. At the end of the open-label phase,
all the participants are tapered down and off opioids, and re-randomized to
two groups, opioid or placebo.
Enriched enrollment is a flawed design because the study population is
not generalizable to all chronic pain patients but only to chronic pain
patients who already like opioids. The study is also no longer double blind
because the participants who continue to experience opioid withdrawal,
which can go on for weeks and months in some people, continue to feel
worse when they’re randomized to placebo. What naturally ends up
happening is that many of the individuals who liked being on opioids and
who are randomized to placebo end up dropping out of the study, so now
the dropout rate is higher in the placebo arm than in the study-drug arm.
The result is that the opioid study drug ends up looking better than placebo,
and the drug gets approved by the FDA.
Here’s an analogy. Imagine you are testing a theory that, to keep kids
happy and well-behaved during lunchtime recess, playing soccer is better
than engaging in arts and crafts. You take the entire third-grade class and
randomly, by drawing names from a hat, divide the students into two
groups: half to play soccer and half to sit at the arts and crafts table and
make hand puppets. At the end, you use some measure to assess whether
kids are happier and better behaved when they play soccer or when they do
art. That is a classic randomized study design.
 Now suppose that instead of the above, you make all the kids play
soccer every day at lunch for two weeks first, before randomizing them to
different groups. Naturally, the kids who already like soccer or are more
athletic or have higher energy will probably enjoy this. The kids who are
naturally unathletic, low-energy, or disinclined to play sports will not like
this. In fact, quite a few of them may simply refuse to participate and may
even bring in notes from their parents asking that they be allowed to sit out
during lunch. At the end of the two weeks, you might have only half the
number of kids still playing soccer because the rest have dropped out of the
study. All clinical studies have subjects who drop out, ending with many
fewer subjects than when the study started.
With the kids left, most of whom enjoy soccer, you now randomly
assign half to soccer, and half to arts and crafts. The kids who get
randomized to soccer are happy. The ones who get randomized to arts and
crafts are not so happy. They miss soccer and are now also fidgety and
restless because their bodies had gotten used to getting exercise during
lunch. Your study results unequivocally show that kids who play soccer are
much happier and better behaved than kids who do arts and crafts, and
every school in the district, as a result of your work, has mandatory soccer
at lunchtime.
The FDA has made some limited innovations to target the prescription
opioid epidemic, but for every step forward, they’ve taken two back. In
2014, the FDA reclassified Vicodin, among the most misused painkillers in
the 1990s and early 2000s, to schedule II, making it harder for doctors to
prescribe it and hence for patients to get it.102 But nearly simultaneously, in
2013, the FDA approved Zohydro, a long-acting version of Vicodin that is
likely to be as addictive as or more addictive than Vicodin. The FDA is
meanwhile keeping drugs like Opana on the market. Opana was approved
in 2011 as an “abuse-deterrent” opioid painkiller, but since then has proven
to be highly addictive when injected. It was recently tied to a 2015 outbreak
of HIV in rural Indiana, as well as a surge in hepatitis C infections in
Kentucky, Tennessee, West Virginia, and Virginia.

The Engine and the Caboose

In 2007 three of Purdue’s top executives pleaded guilty to “misbranding”
OxyContin as less addictive than it is, and Purdue paid $634 million in
fines, the eleventh largest fine paid by a pharmaceutical firm in the history
of the US Department of Justice. Of the fines paid by Purdue in 2007, about
$160 million went to reimburse the federal government and some states for
damages suffered by Medicaid programs, the government health insurer for
the poor.103
Kentucky, one of the states especially hard hit by the prescription opioid
epidemic, refused its reimbursement of $500,000, the only state to do so,
deciding instead to file its own class action lawsuit against Purdue. Similar
class action suits have been filed by Illinois and California. When
Kentucky’s suit against Purdue goes to trial, it will be an unprecedented
event. Purdue Pharma has never gone to trial for OxyContin and has
succeeded in dismissing more than four hundred personal injury lawsuits
related to the use of OxyContin. If Kentucky wins, Purdue is facing an
extraordinary fine, comparable to the class action suits that cost Big
Tobacco billions in the 1990s. Unfortunately, it’s too little too late for the
175,000 people who have died from prescription opioid overdose between
1999 and 2013, not to mention the lives lost before and after.
Manufacturers of opioid painkillers have contributed to the opioid
epidemic that has ravaged the United States, but blame cannot be placed on
Big Pharma alone. Blame lies with doctors as well, especially those in
academia and other positions of leadership who ignored the evidence on
risk and efficacy in pursuit of their own agenda—an agenda that originated
in a desire to help but then lost its way. Blame also lies with regulatory
agencies like the Federation of State Medical Boards, The Joint
Commission, and the FDA, which blindly followed the lead of the
pharmaceutical industry, propagated misinformation, and failed to do their
jobs: to regulate.
Big Medicine was the engine behind the opioid paradigm shift, and Big
Pharma the stealthy and powerful caboose. Big Medicine provided
legitimacy, and Big Pharma the funds to push the message along. Neither
anticipated the success of their partnership, nor the runaway train it would
become when the opioid epidemic took over.
*
The United States endured two opioid epidemics in the twentieth century, the first in the early
1900s, when heroin was marketed alongside Bayer aspirin as a remedy for numerous minor ailments.
The second, in the 1960s, coincided with the Vietnam War and again involved mostly heroin,
although by then heroin was illegal. These prior experiences with opioids made the medical
community understandably reluctant to repeat history’s mistakes.
*
The pharmaceutical industry also engages in direct-to-consumer advertising, that is, it markets to
patient consumers directly. Most people are familiar with Pharma ads on TV promoting better sleep,
hotter sex (or for the middle-aged and older, any sex at all), less pain, and more joy. These
commercials frequently depict an ecstatic woman running through a field of springtime f lowers,
butterflies alighting on her shoulders, and ending with the phrase “Ask your doctor if drug X is right
for you.” This kind of advertising can influence prescribing because doctors are eager to please their
patients, and when a patient asks about a particular medication, a doctor may prescribe it over other
comparable choices.
 5

The Drug-Seeking Patient

Malingering versus the Hijacked Brain

Jim was discharged from the hospital with a peripherally inserted central
catheter, or PICC line, in place to allow for prolonged intravenous access
for the antibiotics he would continue to take in subsequent months to treat
his infection. Weeks later, Jim would discover that the PICC line was useful
for other reasons as well.
He was given a prescription for a one-month supply of Norco, a
combination of acetaminophen (Tylenol) and the highly addictive opioid
hydrocodone (the primary ingredient in Vicodin). Within one week Jim was
taking more Norco than prescribed, and he was prescribed two pills every
four hours, a considerable dose to begin with. Within three weeks, his
month’s supply was gone, and he was back at the same hospital emergency
room asking for more.
Six months after his hospitalization, Jim was ingesting 600 morphine
mg equivalents* of opioids per day. Enough to kill a baby elephant? A
person who had never taken an opioid or anyone who had not taken opioids
for an extended length of time would likely die taking the dose Jim was
taking daily, but Jim’s body and brain had built up such tolerance to the
effect of opioids that, at this point, he needed to take that much every day
just to stave off withdrawal. If he ran out, he experienced opioid
withdrawal, including nausea, diarrhea, insomnia, irritability, anxiety, and
painful muscle cramps—the last being the origin of the phrase “kicking the
habit.”
He told himself he was taking the medication to treat his low back pain,
and therefore he “deserved it.” He told himself he’d quit tomorrow, that he
had it under control, and that it wouldn’t be like alcohol. Meanwhile, he
could think of nothing except obtaining and using pain pills.
By 2013, Jim was spending hours a day going around to different
doctors’ offices, sometimes multiple doctors in one day, but never the same
one within two weeks, looking for prescriptions for Norco and other similar
medications—oxycodone, OxyContin, Vicodin, Percocet, all containing the
same essential active ingredient: opioids. The phenomenon of patients like
Jim going around to multiple health care providers to obtain prescription
drugs is referred to as “doctor shopping.” The trick, Jim found, was to find
clinics that advertised “walk-ins” and “no appointment necessary” because
they were accustomed to patients they’d never met before showing up for
treatment.
Jim’s unassuming appearance worked to his advantage. He typically
wore a T-shirt and track pants, always very clean, and white socks with
white sneakers. His short, dyed black hair gave him a slight resemblance to
Ronald Reagan. He was not too tall or too short, too fat or too thin, too rich
or too poor. He was average, likable, and forgettable.
He exaggerated his symptoms and attempted to validate his medical
claim with objective medical evidence. He got a cane and mastered a
convincing limp. He armed himself with a paper copy of his official
discharge summary, documenting his medical workup, and he made sure to
wear a short-sleeve shirt so his PICC line was clearly visible. He’d tell his
doctors he was still on IV antibiotics, though the need for the antibiotics had
long since passed, and the PICC line was by now a prop rather than a
needed medical device. At each visit, he described his prior treatments and
mentioned the doctors who had treated him in the past by name because, he
sensed, using a specific name legitimized his story. If the doctors
recognized the names, that was even better.
He sought above all to be likable and sympathetic. He seldom
mentioned any drug specifically, deferring to the doctors to come up with it
themselves. He talked about the terrible pain he was in, gesturing, with a
wince in the direction of his low back and legs.
He knew the doctors would have questions, and he was ready for them:
“Why aren’t you seeing your primary care doctor about this problem?”
“He retired.” “She’s on maternity leave.” “He won’t treat pain.”
“What else have you tried for your pain?”
 “Tylenol, ibuprofen, aspirin, acupuncture, trigger-point injections,
physical therapy—nothing works.”
“What are your long-term goals in terms of pain management?”
“I don’t want to take medications. I want to get off this stuff. I want to
get better. But the pain is just so terrible right now . . . ”
Jim used several different strategies to get the drugs he wanted. He was
charming, conciliatory, never pushy, and he lied. He exaggerated his
symptoms. He claimed to be getting treatment he was not getting or had
never gotten. He made promises about quitting he had no intention of
keeping.

Strategies Drug-Seeking Patients Use to Get

Drugs
Patients use many different strategies to manipulate doctors to get the drugs
they want. The myriad ways drug-seeking patients effectively manipulate
doctors can be codified into distinct categories, or personas. These labels
are not intended to denigrate drug-seeking patients but to capture complex
behavior in memorable ways.
Sycophants. Sycophants are patients who flatter and cajole, assuring
their doctor of their competence and compassion, especially as compared to
that of every other doctor they’ve seen. The patient satisfaction surveys give
this technique additional leverage because the communication goes beyond
just the doctor and the patient. It is unveiled for the larger institution to see,
and sometimes the whole Internet world, as in the case of Web-based
doctor-rating platforms that use patient ratings as the only measure.
Senators. Senators are patients who use the filibuster technique, taking
most of the allotted time with the doctor to talk about issues unrelated to the
prescription, intentionally waiting until the last few minutes of the
encounter to bring it up. In doing so, they are relying on the time pressures
they know the doctor is under to tip the doctor over into prescribing because
it is the expedient thing to do. Saying yes to a prescription and ordering it
takes less than one minute. Saying no could take thirty minutes or more,
much less time than the doctor has to stay on schedule.
 Exhibitionists. Exhibitionists are patients who display intense emotions
and dramatic gestures associated with refill requests. Sometimes they
writhe in pain. Other times they achieve various stages of undress to reveal
colostomy bags, surgical scars, congenital deformities. The heightened
theatrics are intended to illustrate a sense of dire need. As one patient said
to me regarding my ability to prescribe him the drugs he was requesting,
“I’m on fire, and you’ve got the hose.”
Losers. Losers are patients who exhibit a remarkable tendency to
misplace medications. With astonishing regularity, these patients run their
medication in the wash cycle, drop them over the side of the fishing boat,
flush them down the toilet—water seems to be a common theme. There’s
also leaving them in a hotel room, being parted from them as a result of lost
luggage during a weekend getaway, and yes, I have even heard of meds
being eaten by the family pet.
Weekenders. Weekenders call for early refills or increased dosages when
their regular doctors, the ones who know them best, are least likely to be
around. Academic medical centers, where less-experienced trainees are
most likely to get calls off-hours, are particularly vulnerable to this
technique. Large health care conglomerates where shift work is the norm
also fall prey.
Doctor Shoppers. Doctor shoppers are patients who go to multiple
doctors simultaneously for the same or similar prescriptions. These patients
seek out clinics where drop-in visits are welcome, and where doctors are
accustomed to seeing a patient once and possibly never again. Emergency
rooms provide the ultimate one-stop shopping, because they are staffed by
many different doctors. According to one study, doctor shoppers seeking
prescription opioids are more likely to be between 26 and 35 years of age,
to pay for prescriptions with cash, and to obtain oxycodone formulations
(2.8 percent), followed by oxymorphone (2.3 percent), followed by
tramadol (2.0 percent).104
Impersonators. Impersonators are patients who assume different
identities at different clinics or hospitals—the inverse of doctor shopping.
Instead of searching around for different doctors, they become different
people.
Dynamic Duo. The Dynamic Duos are patients who present in teams of
two, usually the patient and the patient’s mother, the commonest co-
dependent. While the patient is writhing in pain, the patient’s mother is
crying. Together they make a formidable and persuasive team.
Twins. Twins are the patients who are also health care providers or who
occupy a professional and social class that the doctor relates to. These
patients know how to create a sense of affiliation with the doctor by talking
about the schools they went to, the high-level jobs they’ve had or have, the
people they may know in common. The ones who are health care providers
use their intimate knowledge of the health care system to encourage their
doctors to prescribe for them.
Country Mice and City Mice. Country mice and city mice are patients
who situate themselves on the opposite ends of the savvy spectrum. The
country mouse is the faux-naïf, and the city mouse the slicker. The country
mouse pretends to know nothing about prescription medication and gently
persuades the doctor to suggest the drugs. The city mouse, by contrast,
saunters into the emergency room and announces she is allergic to all pain
medications except intravenous Dilaudid push (the “push” meaning the
syringe with the opioid medication is emptied into the bloodstream all at
once to create an immediate high) with a Benadryl chaser (Benadryl is an
antihistamine known to augment the high of opioids). A nurse practitioner I
interviewed told me that she once treated a city mouse who was so resistant
to transitioning from the intravenous Dilaudid push, given to him in the
emergency room, to the oral or rectal opioid she offered him once he had
been admitted to the floor, that he left the hospital without further treatment.
Bullies. Bullies are patients who use emotional or even physical
intimidation to coerce doctors to prescribe. Bullying may represent one of
the most effective techniques. These patients have a deep understanding of
the fears that plague doctors—the fear of a negative review, the fear of
litigation. Patients exploit these fears to serve their own agendas.
Internet Copycats. Internet copycats use the Internet to obtain
information on how to get drugs from doctors. A Google query of “How to
trick dr’s to give u pain medicine” gives the following result. “The trick—
seriously—is to visit a poor doctor in a poor area of town. Get your
textbook list of requirements, pay cash for your appointment, and be the
perfect patient. Each time, ask for a little bit more painkillers for a little bit
more pain. The doctors want to cover their asses legally and not go to jail or
get sued, but it’s no hair off their back if you’re a lifetime pain mgmt
candidate.” And “Just look up bullsh——t medical problems like
fibromyalgia symptoms and go to the doctor and tell him/her that is how
you feel. Fibromyalgia is just a made up medical term for people that want
pain killers.”
Little Engines That Could. Little engines are patients who plod along,
always communicating enough improvement to convince the doctor they’re
almost there, almost over the hump, while endorsing enough ongoing
distress to continue to receive the desired prescription. These are the same
patients who say “I really want to get off these meds” but never take the
necessary steps to make that happen.

Understanding the Drug-Seeking Patient

For the purposes of this discussion, the drug-seeking patient is the patient
who attempts to obtain a medication from a doctor for his or her own
nontherapeutic or addictive use, not the drug-seeking patient who plans to
give or sell the medication to others (drug diversion).
The prevailing explanation for drug seeking is to accuse the patient of
malingering. According to the Diagnostic and Statistical Manual of Mental
Disorders (DSM), the reigning compendium for describing and
subclassifying mental illness, malingering is “feigning illness with the
conscious intent of obtaining some tangible good not related to illness
recovery.” Malingerers are often seeking a hot meal and shelter (referred to
in medical slang as “three hots and a cot”), a disability payment, and/or
prescription drugs for nontherapeutic use. Patients who are malingering
represent one of the very few instances in medicine in which doctors can
refuse care.
But malingering does not fully capture the phenomenon of drug
seeking. Yes, drug-seeking patients lie and manipulate their doctors, and
they do so knowingly. But if drugs were really all that mattered, they could
obtain them with greater ease from a street dealer or an Internet pharmacy
in less time and often for less money.
The drug-seeking patient is better understood through the lens of
addiction. Addiction is an altered brain state in which motivation for basic
survival has been “hijacked” by the drive to obtain and use substances. The
invocation of the hijacked brain, a common contemporary metaphor to
describe addiction, raises important philosophical questions about the role
of choice, will, and moral responsibility among patients who are seeking
drugs. Dr. Nora Volkow, the director of the National Institute of Drug Abuse
and one of the most vocal proponents of the hijacked brain model of
addiction, has likened the addicted drug-seeking patient to a starving
individual looking for food. If you hadn’t eaten for three days, she says, you
too might do things you previously never would have considered, actions
completely outside your moral compass, just to obtain a morsel of bread.

Neuroadaptation and the Pleasure-Pain Balance

To understand the neuroscience to support the idea of the hijacked brain of
addiction, imagine that the brain has within it an old-fashioned scale with a
straight metal beam atop a fulcrum and equally weighted platforms on each
side. The job of the scale is to register and communicate pleasure and pain.
When the beam is tipped down to the left, the brain senses pleasure. When
the beam is tipped down to the right, the brain senses pain. When nothing is
on the platforms, the beam is level with the ground and balanced, that is,
homeostatic, registering neither pleasure nor pain.
According to George Koob, a neuroscientist who has spent his career
studying the neuroadaptive changes the brain undergoes with chronic
exposure to addictive substances, the preferred position of the beam is level,
in which neither side outweighs the other. To achieve and maintain this state
of equilibrium, the brain is constantly adjusting and readjusting on a
biochemical level. When an individual who likes chocolate eats a piece of
chocolate, the metaphorical beam tips down to the left, communicating
pleasure, mediated by release of the neurotransmitter dopamine. But the
scale wants to be level again. To achieve a level state, metaphorical brain
gremlins start jumping on the opposite side of the scale. This might
translate into decreasing the amount of pleasure-boosting dopamine the
brain makes or decreasing neuronal receptors that recognize dopamine.
Hence the pleasure from eating chocolate is short-lived, and the beam is
level again. The brain has now “adapted” to chocolate, and the second piece
doesn’t taste nearly as good as the first one did.
Drugs and alcohol release much more extracellular dopamine than
chocolate. When drugs and alcohol are consumed, the metaphorical beam
tips much further to the left than it did with a piece of chocolate. The result
is not just pleasure, but euphoria—a high. In the healthy brain, lots of brain
gremlins have to pile onto the opposite side of the scale to balance it again.
Now imagine that an addictive substance is consumed for days and
weeks on end. The gremlins need to work very hard to compensate, making
lots of adjustments on the cellular and neurological level to keep the scale
balanced. The result, over time, is a brain that is significantly altered from
baseline.
What happens if the individual decides he or she no longer wants to
ingest the substance or can no longer obtain it in adequate amounts to
challenge the gremlins? The weight on the left side of the beam is removed,
and the scale begins tipping to the right. The gremlins frantically begin
dismounting, but there are so many of them that they can’t go fast enough,
and hence the scale passes right through equilibrium and continues tipping
to the right. When the scale is tipped to the right, the individual experiences
pain. This pain manifests in the form of acute physical withdrawal, but
more importantly, it is associated with the emotional pain of protracted
psychological withdrawal, including depression, anxiety, irritability, and
insomnia, which can go on for weeks, months, and in some cases, years.
This pain is so intense and overwhelming that it compels repeat drug use,
not to feel high but just to equilibrate the beam and feel normal. Koob calls
this “dysphoria-driven” relapse.17
Tincture of time (most often weeks to months) eventually allows all the
gremlins to dismount the beam, at which point the beam is level, and
homeostasis has been reestablished. But until that occurs, the only way
some addicted persons will be able to arrive at that place is to be put in a
restricted environment where they do not have access to drugs—a
residential treatment center, a wilderness setting, a closed therapeutic
boarding school. A commonly accepted, yet often faulty approach to
dealing with addicted patients is to use the Stages of Change Model
(precontemplation, contemplation, preparation, action, maintenance) and
ask them if they are “ready” to take “action” to stop their addiction. If you
ask an addicted patient if they are ready for treatment while their scale is
still tipped to the right and their thoughts and emotions have been hijacked
by the physiologic compulsion to use drugs, their answer will not reflect
their true thoughts and feelings, but rather the voice of their addiction. I
have seen countless patients who, in the throes of acute withdrawal, have
declined addiction treatment, but who even three days later, once the acute
withdrawal has passed, express an authentic desire for treatment.
Some individuals, however, may never be able to level their tipped scale
and reassert homeostasis in their reward pathway. Their scales may be, in
effect, broken, due to irreversible brain damage that can theoretically be
caused by long-term drug use. These are the same individuals, so the
rationale goes, who may benefit from long-term therapy with opioid agonist
treatment (methadone or Suboxone) as a way to level the beam.

The Rationale for Methadone and Suboxone

The practice of giving an opioid to treat opioid use disorders is one that
began in the United States more than fifty years ago. Two doctors, Vincent
Dole and Marie Nyswander, who happened to be married to each other,
published a groundbreaking study in 1967, in which they demonstrated that
they could improve the lives of persons with severe heroin addiction by
giving them daily doses of methadone, a synthetic opioid (made in the
laboratory). Unlike heroin, which lasts for only a short time (a few hours)
before the individual begins to experience painful opioid withdrawal, the
effects of methadone last at least a day, thereby bridging the gap from one
daily dose to the other. Thus, individuals who have developed tolerance to
and dependence on opioids, and who need opioids just to feel normal, can
take methadone once a day to achieve balance (homeostasis). Dole and
Nyswander observed that heroin-addicted individuals whose lives had been
overtaking by drug-seeking behavior could, with methadone, apply their
efforts to the everyday tasks of living.

Drug-seeking behavior, like theft, is observed after addiction is established and the narcotic drug
has become euphorigenic. The question as to whether this abnormality in reaction stems from the
basic weakness of character, or is a consequence of drug usage, is best studied when drug hunger
is relieved. Patients on the methadone maintenance program, blockaded against the euphorigenic
action of heroin, turn their energies to school work and jobs. . . . Their struggles to become self-
supporting members of the community should impress the critics who had considered them self-
indulgent when drug-hungry addicts. When drug hunger is blocked without production of
narcotic effects, the drug-seeking behavior ends.105

Dole and Nyswander’s groundbreaking work revolutionized the

treatment of opioid addiction and improved the lives of many addicted
individuals. Today, more than 250,000 Americans receive methadone
maintenance therapy, also known as opioid agonist therapy, opioid
replacement therapy, and opioid maintenance therapy. Studies done over
many years in many countries, including Australia, China, France, Iran,
Lithuania, Malaysia, Ukraine, and the United Kingdom, support the
effectiveness of opioid agonist therapy.106 A study in Norway, for example,
demonstrated that individuals currently in treatment with methadone,
compared to injection drug users not in treatment, have significantly fewer
nonfatal overdoses, commit fewer thefts, report less drug dealing, and use
less heroin.107 Treatment for this population not only benefits the individual
user but also contributes to the public good by reducing crime, HIV
infection, hepatitis, and overall mortality, even when those receiving
treatment are not able to achieve continuous drug abstinence.
Opioid agonist therapy is also cost-effective. A US study examining
how opioid agonist therapy affects patterns of medical care, addiction
medicine services, and costs from the health system perspective found that
patients receiving opioid agonist therapy plus addiction counseling have
significantly lower total health care costs than patients with little or no
addiction treatment (mean health care costs with opioid agonist treatment =
$13,578, versus mean health care costs with no addiction treatment =
$31,055).108
Despite the wealth of evidence supporting its effectiveness, opioid
agonist therapy is still controversial. Doctors giving patients an opioid to
treat an opioid addiction seems counterintuitive. Other barriers to
methadone treatment include having to show up at a methadone
maintenance clinic daily, which is stigmatizing for many people. Also,
methadone, especially when first initiating therapy, carries a high risk of
accidental overdose.
Suboxone (buprenorphine-naloxone) is the only FDA-approved opioid
agonist therapy besides methadone for opioid addiction. Suboxone first
became available for the treatment of opioid addiction in the United States
in 2002, after passage of the Drug Addiction Treatment Act (DATA) of
2000. The DATA 2000 allowed doctors for the first time in almost a century
to prescribe an opioid for treatment of opioid addiction from an office-
based practice. (Methadone for opioid addiction can only be prescribed
from specialized methadone maintenance clinics. Only when methadone is
prescribed for pain can it be prescribed in another facility.)* The 1914
Harrison Narcotics Tax Act had criminalized opioid addiction as well as the
use of any opioid “for the sole purpose of maintenance.”
Suboxone has important advantages over methadone. A month’s supply
can be obtained directly from a doctor’s prescription, eliminating the need
to attend a daily clinic. Suboxone has a ceiling effect on respiratory
suppression, which means it does not have the same risk of accidental
overdose due to respiratory suppression that is seen with methadone and
other opioids. It binds and stimulates the opioid receptor as heroin,
morphine, and methadone do, but it does not create the same kind of intense
high users experience with other opioids. It decreases or blocks the effects
of other opioids if taken at the same time.109

Denial
Denial, a common feature of addiction, also plays a role in the drug-seeking
patient, and it has its own unique characteristics when it comes to
prescription drug misuse. Denial is a defense mechanism that seeks to
ignore some aspect of reality, because to acknowledge that reality in that
moment would overwhelm the psyche. An acronym for denial among
members of Alcoholics Anonymous is “Don’t Even k(N)ow I Am Lying,”
which captures the subtle internal dialogue drug-seeking patients have with
themselves to justify their actions. In the context of drug-seeking patients,
denial allows the addicted individual to rationalize compulsive drug seeking
as help seeking: “I need this medication for my pain.” If such patients were
to get their drugs from the street or an illegal Internet pharmacy, they would
be moving out of the patient role and into a more conspicuous “drug-
addict” role, making it that much more difficult to preserve a patient
identity and justify drug use on the grounds of recovery from illness or
injury.
But drug-seeking patients are also motivated by an authentic belief in
their illness narrative. They genuinely believe they are sick and need the
medication to survive. In many instances, they truly are sick, with painful
medical conditions that require treatment. Their belief in their need for
certain medications has been bolstered by their previous experiences with
doctors who also believe in their illness narrative and are willing to
prescribe for them. Neither patients nor their doctors will easily or willingly
unwind these narratives just because the medical establishment decides to
change course in the way such patients are treated.

The Prisoner’s Dilemma and Tit for Tat

Given that patients addicted to prescription drugs are physiologically driven
to seek out and consume those drugs and will manipulate doctors to get
them, and given that doctors are limited in their capacity to know which
patients are benefitting from the drugs they prescribe and which are
misusing or are addicted to them, doctors are caught in what behavioral
economists call the prisoners’ dilemma.
The prisoners’ dilemma describes a situation in which mutual
cooperation is advantageous, but one-sided betrayal is more advantageous
to the one who betrays. The classic example usually put forth by economists
is two criminals arrested for a crime and placed in solitary confinement
with no ability to communicate. If both remain silent (mutual cooperation),
both get parole. If each testifies against the other (mutual betrayal), both
serve two years in prison. If one testifies against the other and one remains
silent (one-sided betrayal), the one who testifies walks free, and the one
who remains silent gets ten years.
A doctor prescribing potentially addictive drugs to a patient who is at
risk to misuse or become addicted to them, which is virtually any patient,
faces a prisoners’ dilemma. If the patient takes the medication as prescribed
(mutual cooperation), the patient’s pain is treated and the doctor fulfills her
mission as healer. If the patient takes the medication other than prescribed
(misuse and one-sided betrayal), the patient gets what she wants (even if it’s
not what she needs), but the doctor has failed in her mission as healer. If the
doctor refuses to treat the patient (one-sided betrayal the other way), the
doctor is rid of a complex patient, but the patient loses access to care.
Nothing in a doctor’s training or education prepares her for the complexity
of this kind of encounter.
Game theorist Robert Axelrod invited academic colleagues from all
over the world to devise computer strategies to compete in an iterative
prisoners’ dilemma tournament. The programs that were entered varied
greatly in complexity, aggressiveness, and capacity for forgiveness. Many
competitors used Bayesian models and meta-analyses to try to predict
future moves. With repeat encounters over a long period of time, each using
different strategies, greedy strategists tended to do very poorly, while more
altruistic strategists were more successful. (The nonretaliating strategy of
“always cooperate” was also one of the least successful strategies,
systematically exploited by “nasty” strategies.)110
The winning strategy in the tournament was contributed by Anatol
Rapoport, who entered Tit for Tat, the simplest of any submission,
containing only four lines of BASIC.111 Tit for Tat begins with mutual
cooperation, but once betrayal occurs, it is followed by retaliatory measures
commensurate with the betrayal, a pattern that continues until mutual
cooperation is reestablished.
Here’s how Tit for Tat looks in the case of a prescription-misusing or
addicted patient. First, the doctor agrees to treat the patient, and the patient
agrees to comply with treatment, that is, take the controlled medication as
prescribed (mutual cooperation). As long as the patient cooperates and takes
the medication as agreed, the doctor continues to prescribe. However, once
the patient betrays the doctor, for example, by visiting another doctor for a
duplicate opioid prescription, the doctor immediately responds by giving
the patient only a one-week rather than a four-week supply of the
medication and insisting that the patient come in weekly for a month to get
urine drug screens before each one-week refill. Note: the doctor does not
verbally reprimand the patient and do nothing, the absence of retaliation.
The doctor also does not fire the patient for betraying the contract—what
game theorists call permanent retaliation. The doctor retaliates
commensurate with the level of betrayal and stops retaliating once the
patient course-corrects.
Although there are no studies exploring the use of Tit for Tat in the
clinical scenario of the prescription drug-misusing patient, there are data
from other populations of drug users implying its potential utility, at least as
a short-term strategy, in the ongoing prescription drug epidemic. Those
under criminal justice supervision (before trial, on probation, or on parole)
are often drug tested at least once per week, but sometimes more often, with
the sanction for a missed test or positive urine screen being one twenty-
four-hour period in jail. These swift, targeted interventions, known as
contingency management, have been shown to reduce drug use and promote
abstinence. By contrast, harsh, nonspecific criminal sanctions for drug use
or possession are generally not an effective deterrent.106
*
Conversions and comparisons between different opioids is typically accomplished by estimating
the equivalent dose of oral morphine, often referred to as morphine milligram equivalents, or MME.
For example, 10 mg of oral oxycodone is approximately equal to 15 mg of oral morphine, or 15
MME.
*
The fact that methadone for the treatment of opioid addiction can only be given at a methadone
maintenance clinic, and methadone for the treatment of pain can be dispensed from any doctor’s
office without any kind of special licensure required, is one of the enduring double standards in
modern medical practice and another illustration of how addiction treatment is marginalized and
stigmatized. Methadone prescribed in pill form for pain, not methadone from methadone
maintenance clinics, has been a major contributor to the high opioid painkiller overdose death rates in
the 1990s and 2000s.
 6

The Professional Patient

Illness as Identity and a Right to Be Compensated

With all the time Jim was spending seeking out doctors to get prescriptions,
he was unable to go to work. He took a medical leave, which was extended
with the promise that he could return to his job when he was able, a lucky
scenario, and one not afforded many workers. Jim thought about applying
for disability income from the federal government, but instead lived off of
his considerable savings during this time. In not applying for disability, Jim
may have inadvertently paved the way for his recovery. One of the factors
that would ultimately propel him into addiction treatment was the need to
go back to work to pay the bills. By contrast, many patients I see who are
on disability become trapped in a situation in which maintaining their
income means perpetuating their illness status, which both fuels
prescription pill consumption and bars the way to addiction treatment.

Staying Sick as a Means of Survival

During a routine Wednesday morning outpatient clinic, Sally rolled into my
office in her wheelchair, her service dog at her side, and began to elaborate
at length on her various medications—Prozac and Zyprexa for mood,
Klonopin and Ambien for sleep, Xanax for breakthrough anxiety, Lamictal
for epilepsy, Requip for restless legs, oxycodone for pain, Vicodin for
breakthrough pain, morphine for more breakthrough pain, Baclofen for
muscle spasms, and Adderall for attention deficit disorder.
At age 29, Sally was receiving more medical care than most 85-year-
olds.
 Looking over her chart, I noticed that neurologists had never found an
explanation for the “leg weakness” that confined her to a wheelchair, nor
any definitive evidence of seizure. Outside of her own subjective
endorsement of symptoms, there was no objective medical evidence to
corroborate her diagnosis.
Moreover, her multiple medications were causing side effects, including
obesity, gum disease, sexual dysfunction, diabetes, and addiction to
painkillers and Xanax. Yet despite these medication-induced adverse
medical consequences, with minimal relief of her original symptoms, Sally
was not interested in changing her treatment. “I’m sick and I’m not getting
any better, doctor. I’ve tried everything, and this is as good as it’s going to
get.” My only utility to Sally was refilling her prescriptions and signing off
on her disability paperwork so she could continue to receive $800 per
month in Social Security Disability Income.
Sally represents a type of patient I see with increasing frequency:
patients who visit a doctor’s office not to recover from illness but to be
validated in their identity as a person with an illness. They are afflicted by
ailments of indeterminate validity, take multiple medications, often ten to
twenty pills per day, and suffer adverse consequences from the very medical
interventions meant to help them, including addiction to prescription drugs.
Their medical charts are replete with phrases like “drug-seeking,”
“secondary gain,” “noncompliance,” “somatic,” “early refill,” and
“medication overuse,” all of which covertly communicate that their doctors
are suspicious of their motives and overwhelmed by not knowing how to
help them. Importantly, most of these patients are poor, undereducated, and
reliant on federally funded disability as their primary source of income. In
other words, they are professional patients.
Professional patients are not simply feigning illness; they are adopting
social roles. Social roles are not created by individuals. They emerge
organically in a given time and place, within a given society, an amalgam of
cultural tropes, social norms, and economic incentives. Each social role
comes with its own rights, obligations, and responsibilities. Writing in the
latter half of the twentieth century, sociologist Talcott Parsons described
“patients” and “doctors” as social roles within modern society. The primary
responsibility of the patient, Parsons argued, is to “try to get well”; the
primary responsibility of the doctor is to “minimize illness and
disabilities.”112
 Although little more than sixty years have passed since Parsons’s
original writings on the social roles of patients and doctors, his ideas no
longer apply to a growing segment of the patient population. Within the last
three decades, a transformation has occurred in American society and
medicine, such that patients are no longer necessarily obligated to get well,
and doctors no longer necessarily obliged to minimize disability. Indeed,
today staying sick has become a means of survival and keeping patients
sick a new way of helping. Poor patients in particular are financially
incentivized to be on disability.

Rising Disability Rolls

According to the work of economists David Autor and Mark Duggan in The
Growth in the Social Security Disability Rolls: A Fiscal Crisis Unfolding,
the number of adults receiving disability through Social Security Disability
Insurance (SSDI) has increased almost twentyfold since 1957. In 1957,
some 150,000 nonelderly adults were receiving disability payments through
SSDI. SSDI is one of three major federally funded programs to financially
support those who cannot work due to illness but who have paid Social
Security taxes through prior employment. By the end of 1977, however, that
number had risen to 2.8 million.113 The two other large government-
sponsored disability programs, Supplemental Security Income (SSI), for
low income or indigent disabled persons, and Veterans Disability
Compensation (VDC), for military personnel with service-connected
disabilities, have likewise seen tremendous growth in the last several
decades.
The largest recent increases in disability claims have been for mental
illness and chronic pain disorders. In 1983, heart disease and cancer
represented the largest fraction of disability insurance awards through
SSDI. By 2003, mental disorders and musculoskeletal disorders (for
example, back pain) constituted the largest fraction of disability insurance
awards, 25 percent and 26 percent, respectively—approximately double
their 1983 rates. Among children, diagnosed mental illness is the leading
cause of SSI disability, a thirty-five-fold increase from two decades ago, far
outdistancing physical disabilities like cerebral palsy or Down’s syndrome.
Among veterans, post-traumatic stress disorder (PTSD) is the most
common mental health service-connected disability, with an increase of
~150 percent in disability benefits payments between the years 1999 and
2004, accounting for 21 percent of all benefit dollars paid through the
VDC.114 Paradoxically, overall health outcomes in adults between ages 50
and 64 have improved since 1984.
So why are more Americans than ever before applying for and receiving
disability income? Autor and Duggan argue that disability programs have
come to “function like a nonemployability insurance program for a subset
of beneficiaries, rather than (primarily) as an insurance program for medical
impairment” (87).113 They note two major changes in Social Security
disability policy in the last several decades which have contributed to this
phenomenon.
First, starting in the early 1980s, the monetary value of Social Security
disability insurance began steadily rising, especially for lower-income wage
earners, making disability more attractive than available employment
options. The 1996 welfare reform bill, which required states to reduce the
numbers on welfare and report that reduction to the federal government,
may also have provided an incentive to states to move poor people to the
disabled category to improve the state’s welfare numbers.
Second, in the mid-1980s congressional disability screening laws were
revised to emphasize applicants’ reported pain and distress and to
deemphasize objective medical criteria. Subsequently, more and more
claimants were filing for syndromes with few or no objective criteria,
especially post-traumatic stress disorder and depression, but also physical
illnesses that are difficult to validate with laboratory or imaging studies
(such as chronic pain, multiple sclerosis, seizure disorders, chronic fatigue
syndrome, late whiplash syndrome, fibromyalgia, myalgic encephalitis,
chronic temporomandibular disorder, repetitive strain injury, sick building
syndrome, Gulf War syndrome, etc.).
Poverty and lack of education are important determinants of who seeks
disability, independent of illness status. In 2004, high school dropout males
were five times as likely to receive SSDI disability payments as males with
a college degree.113 Vietnam veterans who are most likely to be on
disability through the Veterans Disability Compensation program are not
those with the most war-theater exposure or wartime injuries, but rather
those with the lowest predicted earning potential, based on previous
education level and skills.115 Much of the recent increase in new PTSD
claims by Vietnam veterans seeking disability is for conditions that were
not evident on the battlefield, suggesting that their symptoms are as much a
result of their life circumstance since being discharged from the military as
to the military experience itself.116 According to the US Census Bureau’s
figures for 2006, of the 40 million people in America who receive disability
compensation, most are poor and undereducated.

The Complicity of Doctors and Health Care

Institutions
Doctors and health care institutions are complicit in the medicalization of
poverty that encourages the creation of professional patients. The doctor-
patient interaction has in some instances been reduced to little more than a
business arrangement, in which helping the patient secure income becomes
the primary goal—likewise a financially rewarding proposition for hospitals
and doctors.
For-profit firms called “eligibility service providers” are hired by
hospitals to help uninsured patients apply for SSI benefits as a means of
reducing the number of uninsured patients they have to treat. Disability is
usually accompanied by automatic Medicaid benefits. Once patients have
Medicaid, the hospital and clinics can be reimbursed through Medicaid for
services rendered.117
Doctors commonly receive unsolicited mailings, encouraging them to
fill out disability forms in exchange for cash. I received the following
unsolicited e-mail in my inbox in 2014:

Dear Doctor, Millions of Americans are out of work and the new phenomenon is that they are
applying for State Disability Benefits once their unemployment benefits are exhausted. Did you
know that Disability Determination Services pays approximately $175 for a 30 minute office
visit? That’s $2800 per day for a 16 patient load. We have the only software on the market
designed to help you complete the Social Security Disability musculoskeletal exams and get it
turned around in minutes. If you modify your practice to see State Disability clients just one day
out of the week you would add $140,000 to your practice. You would net $136,000 after taking
into account the cost of the software.
 An early historical precedent for the financial incentives afforded
doctors vis-à-vis the professional patient, can be traced to the late 1800s,
when the inception of the railroads led to the establishment of insurance
companies to compensate individuals harmed in railway accidents. Shortly
thereafter, a problem called “railway spine” manifested, defined by a vague
cluster of symptoms such as fatigue and nervousness in individuals who had
experienced even very minor train jarring. Forensic psychiatrists, who had
previously been confined to examining prison inmates, now were needed to
evaluate cases of railway spine, and were of course compensated as well by
the railroad insurance companies for this work. The number of cases of this
condition rapidly proliferated, as did the number of doctors to treat it,
illustrating that the success of railway spine as an accepted diagnosis was
intimately related to the monetary benefit to both victims and healers.118

Professional Patients at Risk for Prescription

Drug Addiction
Professional patients may be at increased risk of becoming addicted to
prescription drugs because of greater exposure to these drugs.
The granting of disability has been shown to increase health care
consumption, which in turn increases risk of exposure to prescription
medications. The granting of disability for PTSD in veterans, for example,
is followed by an increase in the use of both mental health and medical
services, with medical visits increasing by as much as 30 percent and
mental health visits by as much as 50 percent. In those denied
compensation, mental health visits decline by as much as 50 percent in the
postclaim period.114
Professional patients are treated for conditions that rely on each
patient’s subjective endorsement of symptoms: chronic pain, depression,
attention deficit disorder, post-traumatic stress disorder, and so on. These
types of disorders are treated with medications that acutely improve
subjective feelings of pain, anxiety, dysphoria, fatigue, and cognitive
impairment. The medications that target pain, feeling, and thinking are also
the medications with the highest potential for misuse, dependence, and
addiction: opioid painkillers, sedative hypnotics, and stimulants.
 Patients seeking disability may have to take medications to validate
their claims status. In a December 2010 issue of the Boston Globe,
journalist Patricia Wen tells the story of an impoverished single mother
living in the projects of Roxbury who applied for Supplemental Security
Income for her three sons when she could no longer afford to pay her
bills.117 Her neighbors told her about the program and encouraged her to
pursue it. She was initially reluctant to label her sons as having attention
deficit disorder, preferring to view them as rambunctious; but the money—
thousands of dollars per year and automatic Medicaid coverage—was
eventually too good to pass up. Her first several rounds of applications were
denied. Then friends and neighbors told her that her sons needed to be on
stimulant medications like Ritalin or Adderall to get disability approval. She
found a doctor who agreed to put her sons on a stimulant. The next time she
applied for disability, her claim was successful.
Doctors are more likely to prescribe opioids and other addictive
medications to patients on Medicaid,119 many of whom are receiving
disability payments. People receiving Medicaid are prescribed painkillers at
twice the rate of non-Medicaid patients, and they die from prescription
overdoses at six times the rate. New York State Medicaid enrollees are more
likely to die from opioid painkiller poisonings than those not enrolled in
Medicaid: deaths per 100,000 among New York State residents not enrolled
in Medicaid increased from 0.73 in 2003 to 2.82 in 2012. Deaths among
New York State residents enrolled in Medicaid increased from 1.57 to 8.31
over the same period.119 Veterans with PTSD, 94 percent of whom have
VDC disability for PTSD,120 are prescribed opioids for chronic pain at a
higher rate than those not in that category.121
The reasons for higher rates of controlled prescription drug prescribing,
especially opioids, in the Medicaid and PTSD-veterans populations are
unclear, but many doctors I spoke with reported feeling they have little else
to offer these patients, who often lack access to behavioral treatments,
physical therapy, acupuncture, or other alternatives to prescription drugs in
the treatment of chronic pain and mental health disorders.
Furthermore, many patients receiving disability payments have
independent risk factors for addiction, including poverty, unemployment,
social distress, and lack of alternative rewards.122 New disability applicants
cannot qualify for disability based on their addictive disorder alone. A
congressional law passed in 1996 disqualified SSDI claimants with
addiction, terminating about 130,000 beneficiaries. Two-thirds of those
claimants requalified for disability under a different disorder,113 mostly
chronic pain disorders, setting them up for addiction to prescription
painkillers.

The Victim Narrative and Illness as Identity

Professional patients, in adopting the sick role, are vulnerable to developing
an illness identity and a victim narrative, thereby increasing their
dependence on doctors and prescription drugs and decreasing their
likelihood of getting treatment for addiction.
In telling her story, Sally used borrowed language and medical jargon
(“my PTSD,” “my fibromyalgia,” “my depression”). She gave a recitation
of trauma and diseases that lacked the richness and detail that typically
distinguishes one individual’s life story from another’s. Her use of the
possessive pronoun was not merely convenient syntax but also a way of
communicating that illness had become her identity. She saw herself as
perpetually victimized by forces beyond her control and yet wholly
dependent on others for recompense. This created in her an attitude of
resentment and entitlement in equal measure, and influenced her perception
that others misused and maligned her, even when the circumstances and
facts argued against it.
Joseph Davis articulates in the journal Social Problems, “Gaining public
sympathy and help for those putatively injured requires establishing their
moral goodness, as persons innocent of any responsibility or fault for the
harm they suffered” (530).123 Fassin and Rechtman write in their book The
Empire of Trauma: An Inquiry into the Condition of Victimhood, that
“trauma is not simply the cause of suffering that is being treated, it is also a
resource than can be used to support a right” (10).118
Over the last thirty years, illness has become identity and a victim
narrative commonplace. The medical and social sciences are partly
responsible for this trend. They have legitimized the categories of illness
which provide the foundation for new identities. The Canadian philosopher
Ian Hacking, in his article “Making Up People,” argues that our culture
creates people who didn’t exist before. According to Hacking, this process
occurs first by counting people with a certain trait or characteristic through
the application of biostatistics to social sciences, then quantifying those
characteristics (as in the Diagnostic and Statistical Manual of Mental
Disorders), then providing a putative scientific explanation for this new
identity.
Hacking gives as an example the fact that autism was a rare
developmental disorder in 1973, occurring at a rate of 4.5 per 10,000
children, whereas today the autism spectrum disorders—for example,
“Asperger’s”—occur at a rate of 57 per 10,000, spurring the debate about
whether the disorder has increased, detection has increased, or our
expanded definition has increased diagnosis, or all of the above. Whichever
way, says Hacking, the social and medical sciences have created people
with new biologized identities which provide a way “to be a person, to
experience oneself, to live in society.”124
The adoption of illness identities is also driven by the breakdown of
traditional social roles. Illness provides a way to define the self in a rapidly
changing and increasingly fragmented world. Furthermore, ill persons today
are lionized as heroes because they fight a battle against overwhelming
physical forces. In a world in which the struggle for basic survival (food,
clothing, shelter) has become largely irrelevant for most Americans, the ill
person is among the last of the great warriors.
Illness identities furthermore offer a chance for community. Patient
advocacy groups declare national disease-related holidays, hold educational
conferences, produce media, publish literature, and sponsor websites, all
encouraging individuals to regard themselves as distinct and separate
because of their illness. Patient advocacy groups, too, are often funded by
the pharmaceutical industry. For example, CHADD, Children and Adults
with Attention Deficit Hyperactivity Disorder, is a not-for-profit patient
advocacy organization that receives 14 percent of its total revenue
($345,000) from pharmaceutical grants, including the makers of
methylphenidate and amphetamine salts (stimulants).125
Illness as identity is not in all cases a bad thing; it can give people a
sense of purpose and belonging and provide some relief from suffering in
knowing they are not alone. An illness identity is less stigmatizing than
other identities, for example, being unemployed. But when illness subsumes
identity and provides the only roadmap for living, and when treatment
involves the continual ingestion of controlled drugs, then addiction is not
far behind. Furthermore, the victim narrative of the professional patient
almost guarantees that the patient cannot get better. When an individual’s
survival becomes predicated on having a chronic and incurable illness, then
that individual must stay ill.
A colleague with whom I shared care of a professional patient sent me
this missive regarding our mutual patient:

Pt arrived agitated and angry. Last week we had discussed her improvement and I noted that I
thought she no longer met criteria for depression. Over the past week, she experienced panic at
the thought that her disability status (and therefore livelihood) would be taken away if she no
longer qualified for a depression diagnosis. In addition, she received two partial bills for
psychiatry services and assumed she was being billed because she had improved or that her
diagnosis had been taken away. Pt arrived today reporting suicidal ideation this past week and
showed me photographs of her cluttered house to indicate how impaired her functioning remains.

My colleague, when she saw this patient again, worked to help her
imagine a future in which she could be functional and working again. Her
patient continued to be resistant to this idea.
A potential antidote to the victim narrative of the professional patient
might be found in the so-called recovery movement, which encourages
individuals to identify with their illness but not to be victims of it. Instead,
it urges ill people to come together and use the healing power of the
community to triumph over illness.
The recovery movement arises out of the tradition of Alcoholics
Anonymous and other twelve-step self-help groups. One of the mechanisms
by which AA helps people stop drinking is to give them a new narrative.
The AA illness narrative teaches members that their intemperate substance
use is caused by a disease, even going so far as to say that members are
“allergic” to their drug of choice, thereby removing some of the shame
associated with their past behavior. But the AA disease narrative of
addiction is not a fatalistic one, however it may appear on the surface. In
fact, one of the most important tenets of the AA philosophy is that members
are responsible for their life choices. This truth is often misunderstood by
critics of AA, who see the disease model and the Higher Power elements of
the AA philosophy as an invalidation of individual will and choice. To the
contrary, emblazoned on AA literature throughout the world are the three
words “I am responsible.” AA teachings thus embody a paradox: a disease
narrative that speaks to inevitability, but not to helplessness; a spiritual
journey that emphasizes reliance on a Higher Power, but not an abdication
of personal choice or responsibility.

Disability as Safety Net or Social Harm?

I worked with Sally for more than a year to try to whittle down the number
of medications she was on, particularly the addictive ones. I tried to
establish an effective method of communication between myself and her six
other doctors, and to move her on a path toward true wellness. I thought we
were making some headway, but then Sally informed me that she had found
yet another doctor, a sleep specialist, who diagnosed her with narcolepsy
and recommended the highly addictive medication GHB, also known as the
“date rape” drug for its ability to render recipients virtually unconscious for
some period of time. Sally embraced her new diagnosis of narcolepsy like
finding a long-lost friend. She was relieved. The sick role was what she
knew. And when I told her I could not condone the addition of yet another
potentially addictive medication to her regimen, she walked out of my
office, and I never saw her again.
Frueh and colleagues write in the American Journal of Public Health
that “disability policies require fundamental reform to create an effective,
responsive, and flexible safety net. . . . We must ensure that . . . finite
resources are not misallocated and do not foster invalidism.”120 Economists
Autor and Duggan suggest specific ways to reform our current system.126
In the meantime, the sad plight of professional patients today can be
aptly compared to the tragic plight of street beggars the world over,
particularly those who maim themselves or their children to procure an
income, a phenomenon seldom seen in modern America, but one that was
quite common on the streets of nineteenth-century American cities and that
still occurs in some countries today. Like street beggars, professional
patients sacrifice their bodies to make a living, the crucial difference being
that doctors play a role in maiming them, and the medium is addictive
prescription drugs.
 7

The Compassionate Doctor, the Narcissistic

Injury, and the Primitive Defense

Jim continued to obtain enough opioid prescriptions from multiple doctors

to feed his habit for approximately a year. Then one day he went to see one
of his regular walk-in-clinic providers for a refill and was met by a
physician who was so angry he refused even to let Jim be escorted back to
an exam room. “I don’t want to see you back in this clinic ever again!” he
shouted, when he saw Jim’s face. “Get out. Get out!”
What prompted this doctor’s response?
Jim’s insurance company used a tool called a Prescription Drug
Monitoring Program (PDMP), which provides information on all the
prescriptions for controlled medications a patient picks up at a pharmacy
within a given time period (usually a year) and a given geographic region
(usually within that state). These databases gather information collected
from pharmacies by the Drug Enforcement Agency (DEA), including type
of drug, strength and quantity of the drug, date the drug was picked up,
pharmacy location, and which doctor prescribed it. The insurance company
mailed this information to Jim’s doctor, who saw his name among many
other prescribers, all doling out opioid painkillers to Jim.
When Jim’s doctor discovered that he was just one of many doctors
giving Jim opioids, he became enraged, a demeanor at odds with what we
usually consider to be appropriate for the compassionate healer. On a
superficial level, Jim’s doctor’s reaction was understandable. Jim had lied to
and manipulated him, and nobody likes being lied to. On the other hand,
Jim had real pain and real addiction, and he needed medical help. To
understand how a compassionate doctor could respond this way, let us
spend some time looking closely at the psychology, background, and
guiding principles of the average, well-intended doctor.
 Who Is the Compassionate Doctor?
Doctors are by and large pleasers. They make it through the complex maze
of schooling all the way to medical school by figuring out early on what
other people want and providing it. They are temperamentally anxious,
obsessional types, preferring structure and certainty to loose boundaries and
uncertainty.
They are motivated by a higher calling. When they graduate from
college, usually near or at the top of their class, they can choose to go into
any number of professions, from business to law to computer science. They
choose medicine, however, because they are looking for a chance to make a
real difference in the most tangible sense, by saving lives and alleviating
suffering.
Once in medical school, doctors are called upon to empathize with
patients and imagine their suffering as their own, without judgment. They
are socialized to believe their patients, without second-guessing the veracity
of their stories. The relationship between doctor and patients is founded on
an assumption of trust and mutual cooperation.
Once they enter practice, these perennial A-students are intensely
invested in being the best doctors they can be. They are, in other words,
narcissistically invested in being successful doctors. This is not to say that
doctors are narcissists; narcissism is not the exclusive domain of
pathological self-involvement. The psychoanalytic conception of narcissism
leaves room for “healthy narcissism.” Freud described early childhood self-
involvement as a normal and healthy part of development. The
psychoanalyst Heinz Kohut believed that when the narcissistic demands of
early childhood are adequately met by available caregivers, then childhood
narcissism evolves into healthy adult self-esteem.127 The healthy narcissism
of adulthood is what allows us to invest our energy and creativity into the
things we care about to achieve success, however we define it, whether that
activity is bird-watching, parenting, or doctoring.
So how do doctors define success? By mutually affectionate interactions
with patients. These mutually affectionate interactions are often
characterized by a patient’s expression of gratitude. What balm to a doctor’s
soul when the patient says, “Thank-you, doctor, you have really helped
me,” or “Thank-you, doctor, I don’t know what I would have done without
you.” More objective measures of doctoring success matter, too—a
chemotherapy regimen that has eliminated a cancer, or a knee replacement
that allows a patient to walk again. But for doctors working day in and day
out treating patients, many of whom are chronically ill and will never get
better but can only hope not to get worse, the most essential measure of
success is a positive, trusting, mutually affectionate interrelationship.
At its most professionally satisfying, the interaction between doctor and
patient can even approach the spiritual, or what philosopher and theologian
Martin Buber called an “I and Thou” moment: “Man wishes to be
confirmed in his being by man, and wishes to have a presence in the being
of the other. . . . Secretly and bashfully he watches for a YES which allows
him to be and which can come to him only from one human person to
another.”128 These moments of deeply shared humanity, which thankfully
occur often enough between doctor and patient, make all the years of
schooling, all the exams, all the nights on call, all the petty bureaucratic
demands (which seem to get only worse with each passing day) worthwhile.

When the Compassionate Doctor and the Drug-

Seeking Patient Meet
When the compassionate doctor and the drug-seeking patient meet, what the
doctor experiences is anxiety. Maybe not consciously, but there is anxiety
nonetheless. If the doctor mistrusts the patient or questions the patient’s
story, then the doctor is not living up to the principles of empathy and
compassion. If the doctor openly challenges the patient, she risks the
mutually affectionate interaction that is key to measuring her day-to-day
success as a “good doctor.” On the other hand, if she doesn’t challenge the
drug-seeking patient, then she is also not living up to the ideal of the
compassionate healer. In short, the doctor is stuck between a prescription
and a hard place, and the result is anxiety.
What does the doctor do with this anxiety? She buries it by turning to
primitive, largely unconscious defense mechanisms. First described by
Freud, defense mechanisms are automatic, unconscious psychological
maneuvers human beings employ to avoid having to cope with or even
acknowledge uncomfortable emotions. The psychiatrist George Vaillant
classified defense mechanisms into four levels, from pathological defenses
such as denial, to immature defenses such as wishful thinking, to neurotic
defenses such as rationalization, to mature defenses such as humor.129 The
important implication of Vaillant’s classification is that we all employ
unconscious defense mechanisms all the time to defend against all types of
anxiety; and in times of acute distress, defenses mechanisms, even primitive
ones, are adaptive. However, in our everyday lives, defense mechanisms
tend to be maladaptive and should not be confused with coping strategies,
which are adaptive and conscious. Typical defense mechanisms doctors use
with drug-seeking patients include passive aggression, projection, splitting,
and denial.
“Passive aggression” is defined as aggression toward others expressed
indirectly or passively, most often through avoidance and procrastination.
Examples include finding reasons to cancel visits with such patients,
rounding quickly on them in the hospital, or not at all, writing extended
refills to minimize contact, not returning their phone calls, etc.
“Projection” is attributing a moral or psychological deficiency in
ourselves to another individual or group. Doctors often project the contempt
they feel for themselves around lax prescribing onto their patients. It is
easier for doctors to see patients as morally deficient than to acknowledge
having abdicated their responsibilities to patients by prescribing
medications that might be harming rather than helping them. In this
scenario, the doctor thinks “What is wrong with this patient? Can’t she get
it together and take the medicine like she’s supposed to?!” instead of “What
is wrong with me, and with the system, that I would prescribe a medication
I know is not helping?”
The “splitting” defense involves segregating experience into all good
and all bad categories, with no room for ambiguity or ambivalence. Doctors
typically engage in splitting by mentally segregating drug-seeking patients
into the category of “bad patients” as distinct from “good patients.” A good
patient takes many forms depending on the doctor, but is often the patient
who expresses gratitude, gets better, or can be seen quickly. Bad patients are
those who threaten the doctor’s sense of competence as healer or who
trigger negative emotions, such as anxiety, impatience, or anger.
Of all the primitive defenses doctors employ against drug-seeking
patients, the most common and insidious is probably denial. “Denial” is the
refusal to accept a threatening reality by simply believing it doesn’t exist.
This includes refusing even to perceive or acknowledge certain truths, for
example, that we are in the midst of a national prescription drug epidemic.
For the past two decades, even very good doctors have ignored suspicious
patterns of medication use, dispensed early refills, disregarded escalating
doses, and failed to access data that would give them the information they
need to make a more accurate assessment of current medication use, such as
their state’s prescription drug monitoring program (PDMP). Despite a major
public health campaign to encourage doctors to register for and utilize their
state’s PDMP, only 35 percent of doctors practicing in the United States
today access this resource.130 Time constraints hinder doctors’ ability and
willingness to gain access to and utilize the database, but without checking
the PDMP, responsible prescribing of controlled drugs in the modern health
care system borders on impossible.
New legislation in some states mandates that doctors gain access to their
state’s PDMP. Some states have even gone further, requiring that doctors
check the PDMP before writing a prescription for any scheduled
medication.131

Narcissistic Rage, Retaliation, and Its

Consequences
What happens when primitive defenses like denial no longer work, for
example, when the prescription drug–monitoring database shows overt
drug-seeking, and the doctor is forced to acknowledge that she has been
supplying drugs to an individual who has been misusing them? At this
point, the doctor is unmasked as nothing more than a gatekeeper of goods
and services, or worse yet, a drug dealer, and she experiences a narcissistic
injury. A narcissistic injury strikes at the heart of her sense of competence
and self-esteem. It is extremely painful to experience, and the reaction is
primordial, reflexive, and hostile. Jim’s doctor’s reaction—his unbridled
rage and rejection of Jim—is a classic example of a narcissistic injury
followed by narcissistic rage and retaliation. The idealized response, by
contrast, is compassion and professionalism even in the face of these
challenges.
 Jim’s doctor is not alone. In the last five years, the entire medical
profession has experienced a narcissistic injury as a result of the media
spotlight highlighting the harm done to patients from drugs obtained from
doctors, tarnishing doctors’ reputations and publicly shaming them. As a
result, some doctors have not merely become more cautious about
prescribing opioids to patients in pain but have gone so far as to refuse to
treat pain, declaring it to be out of their scope of practice. These refusals
have become so prevalent that drug-seeking patients have earned their own
moniker, coined by Dr. Steven Passik: “opioid refugees.” The term is apt, as
one imagines these patients wandering from clinic to clinic trying to find a
doctor to treat their pain. Furthermore, the rejection of these patients is not
likely to be attributable to the stigma of addiction: doctors don’t throw
patients out for misusing alcohol, smoking cigarettes, or even being
addicted to heroin. It is the doctors’ complicity in the patient’s addiction
which triggers the narcissistic injury and the retaliatory response.
This kind of permanent retaliation has created more problems than it has
solved. Some patients may be turning to illicit sources of opioids—namely,
heroin—since doctors are no longer willing to prescribe for them. However,
the relationship between doctors’ prescribing patterns and the initiation of
heroin use remains unclear.132 What is apparent is that heroin use has
increased since 2011, as have heroin-related overdose deaths.

Opioid Refugees
My patient Macy became an opioid refugee. I first met her in the pain clinic
where I was asked to assess whether or not she had become addicted to
prescription painkillers, and more importantly, what might be done for her
if she had. When she first saw me, she was in her early twenties. I was just
one stop in a very long road of doctors. As I came to know her, I realized
that her story started with the story of her father, Mike. He was her primary
caregiver when she became ill in her mid-teens.
Mike grew up poor in the 1980s in the drug-ridden neighborhood of
East Oakland, which transitioned in a single generation from a mixed ethnic
middle-class neighborhood to a predominantly poor black one, notorious
for gang drug warfare. Mike was the youngest of five children, and every
member of his family, except Mike and his oldest sister, was addicted to
something.
As soon as Mike was old enough, he got out of East Oakland and started
a family of his own. He was determined to give his kids a better life, as far
away from drugs as possible. He and his young wife moved to a townhouse
in Fremont, a middle-class community south of Oakland. They had two
daughters: first Katherine, and then, seven years later, Macy came along.
Their life was complete.
When Macy was a junior in high school, she began experiencing
unbearable leg pain. Mike, to whom she had always been especially close,
wasn’t sure what to make of it and assumed it was growing pains, so did
nothing. But a month later, Macy collapsed while playing volleyball at
school and was rushed to the nearby emergency room. The doctors
performed a number of tests and couldn’t find anything wrong with her.
Despite the absence of any pathology, they gave her intravenous morphine
to treat the pain and sent her home. Two weeks later Macy was back in the
emergency room with the same pain. More tests revealed an unusual mass
on her diaphragm and on her ovary. The doctors worried it was cancer, and
they switched from intravenous morphine to intravenous Dilaudid, and she
was admitted for surgery to remove the tumors.
As it turned out, the mass on her ovary was a teratoma, a benign growth
of no consequence. The mass on her diaphragm was a bit of lung tissue,
also benign, the resection of which was more involved and required yet
another hospitalization and more surgery. The doctors hoped the removal of
the masses would eliminate Macy’s pain, although a relationship between
the masses and her pain had never been clearly established. In the
meantime, she was given intravenous morphine, Dilaudid, and
hydrocodone, all potent opioids with addictive potential, during and after
each surgery. Altogether, Macy was hospitalized for two months, October
and November of 2010, and barely remembers any of it because she was so
altered by prescription painkillers.
At no point in the course of Macy’s medical procedures was the risk of
opioid addiction discussed. Nor was Macy’s family history of addiction
considered relevant. When Macy’s various surgeries were complete, her
doctors declared that she should be pain free. Despite having received
heavy doses of opioids daily in the hospital for two consecutive months,
Macy was sent home without a single pill. For the next six weeks, she
experienced excruciating opioid withdrawal—nausea, vomiting, fever,
chills—as well as unbearable muscle and bone pain throughout her body,
even worse than the original leg pain.
In the grips of opioid withdrawal, Macy would lie on the floor
screaming and crying out. Her parents, unsure what else to do, took her
back to the local emergency room every few days, where she was given the
opioids her body craved and promptly discharged again. Sometimes the
doctors would readmit her to the hospital and give her intravenous
morphine to control her pain, then discharge her again without opioids,
follow-up, or any semblance of a treatment plan. Between 2012 and 2014,
Macy’s parents took her back and forth to the emergency room in an
endless cycle of despair and frustration. The doctors never seemed able to
tell them what was wrong with Macy, or how to help her, except for writing
more opioid prescriptions.
Then, in 2014, on one of the emergency room visits, the doctor came
out of the room and said to Mike with barely veiled hostility, “Is your kid
on drugs?” He was implying street drugs like heroin, not the painkillers
Macy’s doctors were prescribing, although chemically speaking there is
almost no difference between the two. Would his reaction have been the
same if Macy were white instead of black?
“No,” said Mike, without a moment’s hesitation.
“How do you know?” challenged the doctor.
“I know because I know my daughter, and because we’re with her all
the time, and because she’s not hanging out with other people doing drugs.”
“Your daughter is a drug addict,” the doctor said. “Don’t come back
here for pain medicine again.”
Mike said nothing. He was without words. He gathered Macy up in his
arms and drove her home. When he got her there, she lay on the floor,
moaning and crying out.
“Give her some pain pills,” he said to his wife and daughter Katherine,
who were looking on helplessly.
“They’re all gone,” said his wife, a pleading look in her eyes.
“Dammit,” Mike shouted. He wanted to shut his eyes and make it all go
away. Then he made a decision.
“That’s it,” he said, grabbing his car keys. “If those doctors won’t help
her, I will.” Without another word, he left the house and got in his car. He
headed back to the old neighborhood, silent tears streaming down his
cheeks. He still had some old friends who sold drugs. He would find them
and buy some Percocet, or some heroin if he had to. That would stop
Macy’s pain.
As Mike was driving, a memory from his childhood intruded on his
thoughts. He was crouched at the base of the chimney in his childhood
home, tracing the outline of the inner brickwork with his chubby fingers,
looking for the hole between bricks where the mortar had long ago
crumbled away. He felt the divot and shoved his fingers inside, hoping for
the crinkle of plastic. He found it. He pinched his fingers to get a hold of
the bag and slowly pulled it out.
“Mommy, Mommy,” Mike called, “I found one!”
He ran to the kitchen holding the plastic bag in front of him, the little
blue and red pills bouncing around inside of it.
His mother was cleaning the kitchen, tired after working one of the
many jobs she had over the years—housecleaning, cooking at a local diner,
working the line at the Del Monte Cannery, forklift driving. Mike was her
fifth child, with a different father than the rest, her child of that no-good
drunk she sent away the day Mikey was born, knowing in her heart he
wasn’t going to be the father her son needed. She dried her hands on her
apron and folded the little boy in her arms.
“You found one, so you get a dollar from me,” she told him, “just like I
promised.”
She reached inside her purse and handed him a dollar bill.
“Now you listen to me,” she said, kneeling down and looking him in the
eye, “I don’t want you ever doing those drugs like your brother and sister.
It’s no good, no good.”
“I won’t Mama,” he said, “I promise. I don’t ever want to make you
cry.”
As if waking from a dream, Mike took the next exit off the freeway,
turned the car around, and drove home again. When he got home, he
bundled the still crying Macy back into his car and took her to a different
hospital emergency room. After hours of waiting, the doctor finally came.
Mike turned to him and said, “This is my daughter Macy, and she has
terrible pain all over her body which no one can understand. She is also
addicted to pain pills, and doctors made her that way, so don’t turn your
back on her. Don’t judge her. Help her.”
This new doctor, perhaps humbled by Mike’s desperate admission, took
Macy in and admitted her to the hospital, using the occasion to get her a
treatment plan that included assessment and treatment for addiction, which
had never previously been suggested or offered and which is how she
eventually ended up with me.
Once in addiction treatment, Macy’s problems did not magically
disappear, but with time, patience, courage, and effort, Macy made her way
slowly to a better place, with decreased pain, improved function, a job, and
plans for the future, which Macy also deserves.

A Doctor’s Obligation
We doctors and other health care professionals have a heightened obligation
to patients who have become addicted because of the treatment we have
provided. We simply cannot turn these patients away to fend for themselves.
Many of them become addicted without even realizing what has happened
to them. Most of them have serious medical conditions that warrant medical
attention, in addition to a life-threatening iatrogenic problem. Yet we shun
them. Refusing to treat patients whom we discover are misusing
prescription drugs is not an ethical or helpful response to the prescription
drug epidemic.
 8

Pill Mills and the Toyota-ization of Medicine

After being exposed by his insurance company as a “doctor shopper,” Jim

was forced to travel farther to clinics he had never used before and to pay
cash for his medical visit, usually about $80 per visit, as well as for his
medication at the pharmacy.
One day, Jim went to a new clinic he had never visited before, farther
from home, in a thriving part of Silicon Valley. He walked up to the
receptionist desk to make his payment, but to his surprise, the receptionist, a
fashionably dressed woman in her twenties, informed him that he would
pay after his visit with the doctor, not before. That was unusual. In Jim’s
experience, these walk-in clinics always wanted their money upfront. Jim
mentally shrugged and took a seat in the waiting area.
He found himself in a typical doctor’s waiting room—chairs, a table
with old magazines on it, a plastic rubber tree in the corner. Only one other
patient was waiting with him: a thin middle-aged woman who looked worn
and anxious, unable to sit still in her seat. Jim immediately recognized the
signs of opioid withdrawal. When she told Jim she was there for pain, Jim
started to relax. He was in the right place. The receptionist, who apparently
also doubled as the nurse, called the woman’s name and ushered her
through a heavy door. The woman came back out less than five minutes
later with a prescription in hand. Jim saw this too as a good sign. This
doctor didn’t mess around.
The receptionist-nurse escorted Jim to an examination room and took
his vitals. His blood pressure and heart rate were both elevated, because his
supply of opioid medication had started to run low, and he was in mild
opioid withdrawal. The nurse noted his vitals on a piece of paper and left
him in the room to wait for the doctor.
 The doctor, a man about Jim’s age, came into the room. He was wearing
a suit, not a white coat. He was talking on the cell phone, apparently angry
about a business deal gone awry. Jim remembers him saying “We shouldn’t
have sold that stock.” The doctor didn’t acknowledge Jim immediately, but
instead paced in front of him, still angrily talking on the phone. This was
not usual doctor behavior for Jim, and he got a little nervous. When the
phone call ended, the doctor put his phone into his pants pocket, turned to
Jim, and said,
“How can I help you?”
This was more like it. Jim launched into his usual routine. But instead of
his story eliciting the questions and empathic murmurs he was used to, this
doctor just stared at Jim and said nothing. He did not read the discharge
summary Jim was trying to hand to him; he declined even to take it in his
hand. Only when Jim held up his left arm to show off his PICC line did the
doctor finally respond, but not in the way Jim had expected. The doctor
reached out and dismantled the bandages around the PICC line, as if
checking to see that the catheter was really inserted into his vein and not a
dummy catheter made to look like a real one. Once he had presumably
satisfied himself that it wasn’t a fake, he didn’t bother to reapply the
dislodged bandages but left them in disarray.
Jim said, “Um, do you think you could at least put on a new bandage?”
The doctor didn’t respond. He looked at Jim knowingly and said, “For
pain, it’s $200.”
“Huh?” said Jim. He wasn’t following.
“I’ll give you thirty Norco, but the visit is $200 for treating pain.”
Awareness dawned on Jim. This wasn’t a medical visit, it was pure and
simple a business transaction. “No way,” he said. “No way am I paying
$200. The usual fee is $80.” But he wanted, he needed those pills. “I’ll give
you $100 and that’s it.”
“$200,” said the doctor.
“I’m not going to let you screw me,” said Jim, and got up to walk out,
his limp gone, the cane hanging loosely from his hand.
“Okay. $150,” said the doctor, when Jim had gotten as far as the door.
Jim stopped and imagined what the rest of the day would look like for
him if he didn’t get those pills. Most likely he’d spend it in the bathroom,
spilling the contents of his gut from both ends. He turned to face the man
waiting by the exam table, and then swallowing what was left of his pride,
he fumbled for his wallet, pulled out $150, and stretched out his hand. He
was going to make the man come to him. The doctor walked over to Jim,
took the money, and then took out his prescription pad. He wrote a
prescription for Jim for a month’s supply of Norco.
The receptionist didn’t even look up as Jim walked out the door.
Later Jim would reflect, “Hunting down those drugs is horrible. You’re
craving them, and you’re on edge because you’re withdrawing, and then
you have to scam some doctor, and that’s a lot of work.”
Jim’s encounter with the drug dealer pretending to be a doctor was the
moment he realized he had become a drug addict pretending to be a patient.

Corrupt Doctors and Pill Mills

The doctor who demanded cash in return for writing Jim an opioid
prescription was indeed a drug dealer, although he had “MD” behind his
name. He was not alone. Doctors more interested in money than in the well-
being of their patients took advantage of the rising demand for opioid
painkillers in the 1990s and 2000s as a way to get rich quick. Certain areas
of the country were hit worse than others. Florida became an epicenter for
ethically compromised and frankly illegal exchanges of prescriptions for
cash between doctors and patients. In 2010 alone, manufacturers shipped
enough oxycodone pills to Florida for every state resident to have thirty-
four pills, that is, 650 million oxycodone pills.133 In 2011, Florida boasted
856 pain clinics, many of which became known as “pill mills”—places
“patients” could go and almost be guaranteed a prescription for an opioid.
Since 2011, following a law-enforcement crackdown on pill mills, the
situation has improved. In 2013, the number of oxycodone pills shipped to
Florida dropped below 313 million, the number of pain clinics dropped to
367, and opioid overdose deaths declined.133
To hear of doctors who unequivocally abdicate their ethical and
professional responsibilities to their patients for secondary gain is a source
of shame for all doctors. Yet are the rest of us so very different? All of
health care has become overwhelmed by a hucksteresque opportunism, in
which making a buck is the driving force behind practicing medicine. Even
those of us who want to help find ourselves trapped in a bureaucratic maze
of maximizing profit. The enormous pressures on doctors today to prescribe
pills, perform procedures, and please patients, all within a disjointed
medical bureaucracy and all with an eye on the bottom line, has contributed
to the current prescription drug epidemic.

The Industrialization of Modern Medical Care

The increasingly industrial-scale, capitalistic approach to medicine was
brought home to me one day in May of 2014, when I received the following
invitation: “Please join us for a Kaizen on frequent visitors to the
emergency room.” I had no idea what “Kaizen” meant, although the writer
of the e-mail seemed to assume this was universal knowledge.
Kaizen, I soon learned from Wikipedia, is Japanese for “change for the
better.” The Kaizen Method was famously adopted by the Toyota
automobile company, encouraging workers on the assembly line to stop the
moving production line if they identify any abnormality of production parts.
Workers are also encouraged to suggest improvements to resolve the
abnormality. Kaizen goals include “gauging measurements against
requirements,” “innovating to meet requirements,” “increasing
productivity,” and “standardizing how to improve operations.”134
The assembly line in a Toyota factory today is not much different from
Ford’s assembly line of the early 1900s. Workers are assigned to one
specific production task at a specific station. The car arrives at the station,
and the worker performs the specified task over and over again on each car
that comes by. Expertise is measured by the workers’ ability to “meet
requirements.” It would not be advantageous for a worker to decide one day
to turn the screw left instead of turning it right, or to use yellow paint when
the car is meant to be blue.135
Doctors today work in integrated health care systems. During the 1990s
and 2000s, there was a mass migration of doctors out of private practice and
into managed care organizations. Seventy percent of US physician practices
were physician-owned in 2002. By 2008, more than half of US physician
practices were owned and operated by hospitals or integrated health
delivery systems, and that number just continues to rise.136 The reasons for
this shift included new payment structures and care models that have made
it difficult for private practice to remain a viable option. Also, the younger
generations of doctors, an increasing number of whom are women, are
invested in preserving a work-life balance, and hospital employment makes
it possible to have more flexible hours and protected off-duty time.
The migration of doctors into integrated health care systems (hospital
factories) has transformed medical treatment. Doctors work much less
autonomously. Treatment options are often dictated by hospital
administrators, Joint Commission (see chapter 4) guidelines, and third-party
payers (health insurance companies). Like assembly-line workers, doctors
are expected to “gauge measurements against requirements,” “innovate to
meet requirements,” and “increase productivity.”
No longer are doctors and patients alone in the exam room. They are
accompanied by a host of invisible partners with demands that may have
little to do with treating illness: Patient Relations stands gazing into the
mirror, a patient satisfaction survey on a clipboard in her hand; Billing is
standing on the scale, the numbers on display never far from his mind;
Disability Claims sits with one leg in a cast, propped on the empty chair;
The Joint Commission is digging through a file cabinet, a magnifying glass
in hand; Private Insurance is occupying the chair intended for the patient,
distracted and encumbered by a stack of prior authorization forms; the
Centers for Medicare and Medicaid Services, morbidly obese, is leaning
precariously on the edge of the exam table; Big Pharma hides in the corner,
just out of sight, confidently spinning a drug company pen; the State
Medical Board is hovering behind the doctor, looking stern and unyielding;
and two lawyers, the hospital’s Legal Counsel and the patient’s Lawyer, are
facing off, fists raised, ready to do battle. Time personified is there, ticking
steadily, reminding the doctor that time is short and other patients are
waiting.
The impact of this transformation on health care delivery, and its
contribution to the prescription drug epidemic, cannot be underestimated. I
receive monthly billing statements informing me whether or not I am
meeting the clinical billing requirements set for me by my employer. They
come as an e-mail complete with pie charts, graphs, and tables. Whereas I
used to worry mostly about how best to treat my patients, I now spend time
worrying about my billing targets and what I can do to change my practice
patterns to meet them. When I rise above the line graph of my expected
quota, I feel a surge of triumph, even a little surge of dopamine. When I dip
below, I feel anxious about job security.
To more efficiently meet the billing quota (“innovate to meet
requirements”), doctors do the math. If a psychiatrist provides
psychotherapy (that is, spends time talking to the patient) for fifty minutes,
he or she generates 2.79 Relative Value Units (RVUs). RVUs are the
number assigned by Medicare and adopted by many other third-party
payers to gauge the monetary value of a medical visit or intervention. At
2.79 RVUs, the hospital can charge $300. As a point of comparison, a
screening colonoscopy (in which the doctor inserts a camera into the anus
and up the gastrointestinal tract to look for disease) takes about 13.5
minutes and generates 15 RVUs, for a monetary value of $500.137 Hence, a
gastroenterologist (doctors who do colonoscopies) can theoretically
generate five times what a psychiatrist doing psychotherapy can in the same
amount of time.
But if a psychiatrist writes a prescription for a patient (a service called
“medication management”), doing away with talk therapy and spending as
little as a few minutes with a patient, he or she can bill a minimum of $230
for this service and, more importantly, can see many more patients per unit
time. It is no wonder, then, that a whole generation of psychiatrists now
calls themselves “psychopharmacologists,” doing nothing more than
prescribing psychotropic drugs.
The pressure to see more patients per unit time and to bill more per
patient pervades all of medicine, encouraging doctors to continue to
prescribe drugs. A family medicine doctor admitted to cherishing the
patients who only need a quick refill: “Those are my easiest patients. They
are scheduled for ten minutes, but if I give them what they want, they’re out
in five. Then there’s hope I can catch up and get home at night.” Most
doctors are not mercenaries. They care about their patients and want what is
best for them. But the pressures to get patients in and out quickly can be
overwhelming.
Susie, a young emergency room doctor, finished her residency in
emergency medicine and then opted for an additional year of training in
addiction medicine. She wanted more experience treating patients with
addiction because she had witnessed so many patients coming through the
emergency room with serious alcohol and drug problems, including
prescription drugs.
 After completing a one-year fellowship in addiction medicine, Susie
took a job in 2014 as an emergency room physician in a Bay Area hospital,
where she continues to work today. She gets no base salary, no hourly
salary, no retirement, and no benefits, including no health insurance. She
pays for her health insurance separately through a private insurer. Health
insurance costs her $800 per month. Although she is technically an
employee of the hospital, she gets paid like an independent contractor. She
makes 22 percent of what she bills. If she bills $7,000 in an eleven-hour
shift, she makes $1,540. The more she bills each patient, the more money
she makes.
“Whether I spend a lot of time or a little time with one patient,” Susie
said, “I get paid only for what I bill. If the crux of my interaction with
patients is a conversation, I lose dollars, because talking doesn’t pay.”
When Susie encounters patients whom she suspects are misusing,
diverting, or addicted to prescription drugs, she tries to take a little more
time to talk with them about her concerns and looks at the prescription
drug–monitoring database to assess the number of prescribers and types of
prescription for controlled drugs they’ve obtained in the last year.
“But a lot of the time it’s easier not to put up a fight and just give them
the drug they want.”
When Susie slows down to take more time for her patients, not only
does she personally make less money but her corporate boss makes less
money as well. Susie has been strongly advised to improve her numbers.
One trusted colleague, someone Susie considers to be a “good doctor,” told
her to “just give them what they want and get them out the door.” Susie’s
job represents an extreme form of the incentive-based compensation
packages that many hospitals and health care delivery systems are moving
toward.
If she could do it all over again, would Susie still practice medicine?
“I like people. I like helping people. If I could go back, I think I’d still
do medicine. But the practice of medicine is so different from what I
thought it would be. I’m not someone who has ever been focused on money,
but I am getting more focused on money now.”

Patient Satisfaction: A Measure of Good Care?

The use of patient satisfaction surveys in health care is another example of
the corporatization of medicine, and it has contributed to the prescription
drug epidemic.
The idea of using surveys to assess patients’ satisfaction with their
medical care began in the 1980s. The rationale was based on a handful of
studies showing that patients who are better satisfied with their care are
more likely to be compliant with treatment and return to the same provider
or facility the next time they need treatment.138 “Treatment compliance”—
doing what the doctor says—and “continuity of care”—seeing the same
doctor over time—theoretically lead to improved patient outcomes. They
are also good for the financial security of doctors, clinics, and hospitals.
One of the earliest organizations to turn health care surveys into a
profitable business was Press Ganey Associates, founded in 1985 by Dr.
Irwin Press, PhD, an anthropologist, and Dr. Rod Ganey, PhD, a statistician.
On its website, Press Ganey describes what it does as “driving targeted
performance improvement.” The website goes on to state that “to improve
the patient experience, health care providers must first be able to see and
understand the complex relationships between satisfaction, clinical, safety
and financial measures. Press Ganey’s unique suite of solutions gives every
patient the opportunity to be heard, integrating their voices with these
distinct data streams and seamlessly weaving together millions of patient
touch points.”139
Patient-satisfaction surveys coincided with a larger “patient-centered
care” movement in medicine, advocating for the patient to be viewed as the
central figure in health care services. Today, many health care systems ask
patients to fill out written or computerized surveys, rating their impressions
of their doctors or the treatment they’ve received.
Although patient satisfaction surveys may be useful tools for improving
certain aspects of health care, access, cost, and convenience, there is little or
no evidence that patient satisfaction leads to improved medical outcomes,
and some evidence to suggest that it may in fact lead to worse medical
outcomes. In a study published in 2012 in the Archives of Internal
Medicine, higher patient satisfaction was associated with higher
consumption of health care services, higher prescription drug use, and
increased mortality.140
 Patient satisfaction is tightly linked to expectation, and when a doctor-
patient interaction involves a “bad surprise,” defined as care that is contrary
to what was expected or goes against social norms, then patients are more
likely to express dissatisfaction.141 Nonetheless, good doctoring involves
being willing to tell patients things they might not want to hear, such as
concerns about substance misuse or addiction, or the need to withhold
certain treatments because the likelihood of harm is too great.
The persistent use of patient satisfaction surveys, despite the lack of
evidence to support their contribution to good care, and emerging evidence
to suggest they may be linked to worse care, is rooted in financial
incentives. Patient satisfaction has become, in many health care institutions,
a “quality measure.” A quality measure is one of the ways hospitals are
rated by organizations like The Joint Commission and then ranked one
against the other. This is not just a measure of pride but is also tied to
financial reimbursement from third-party payers like the Centers for
Medicare and Medicaid Services (CMS). CMS (federally funded health
insurance for the poor, elderly, and disabled) collects data regarding patient
satisfaction through the use of the Hospital Consumer Assessment of
Healthcare Providers and Systems (HCAHPS) survey. The HCAHPS
survey queries a random sample of adult patients two days to six weeks
after discharge from the hospital and asks them about their hospital
experience. A typical question on the survey is: “How often did the hospital
staff do everything they could to help you with your pain?” In one year,
HCAHPS collects hundreds of patient surveys from each hospital it
reimburses. Scores on the HCAHPS survey can impact how much CMS is
willing to reimburse the hospital for its services. Lower patient satisfaction
means lower reimbursement. One emergency room that was struggling with
low patient satisfaction scores implemented a policy of Vicodin “goodie
bags” for each patient on discharge.142
For individual doctors, poor ratings on patient satisfaction surveys is a
source of professional shame and, in some settings, can hinder professional
advancement. My 11-year-old son was doing his homework on the
computer, when for some reason he decided to google my name. One of the
sites that came up was a doctor-ranking website with an evaluation of my
professional abilities. My son called me into his room and said, “Mom, is
this you?”
 I looked at the site and, after taking a few moments to figure out what it
was, realized that this particular patient, who called himself “Corey”—I
don’t remember him or even know if this is his real name—gave me one out
of four stars. I don’t believe zero stars was an option or I’m sure he would
have given me zero. He wrote in the comments section: “Really wish I had
seen this site’s reviews before making an appointment with this physician.”
(There were in fact no other negative reviews on the site, which made this
statement rather inexplicable.) “She provides the kind of care that will make
you wish you had never sought help in the first place. Wrong diagnosis.
Wrong medication. In some cases this can be terrible. Seek help from
someone else.”
I was flooded with shame, enhanced by the fact that my own son had
found such a negative review on the Internet. Who else might have seen it?
Perhaps I had told Corey I wouldn’t refill a medication he was expecting to
get. Perhaps with the next patient, I would just fill it. One pain medicine
doctor I spoke with admitted that he had prescribed medications to patients
he knew were misusing and addicted to them for the sole reason of avoiding
that patient going onto Yelp and giving him a bad rating.

Practicing with Blinders On—Not Toyota after

All?
Good communication between doctors today is essential to good care. Most
patients have more than one doctor taking care of them, or they change
doctors frequently due to insurance changes and other provisions of the
managed care environment. Each doctor is busy prescribing the pills he or
she believes will treat the patient, while other doctors are prescribing other
pills. It is entirely commonplace to encounter a patient who is getting a
stimulant from a psychiatrist for attention deficit disorder, an opioid
painkiller from a pain doctor for fibromyalgia, and a benzodiazepine from a
primary care doctor for sleep.
One of the promises of integrated health care systems, and their
integrated electronic medical records, is that it will be easier for doctors to
communicate with one another, so the right hand knows what the left hand
is prescribing. Unfortunately, antiquated privacy laws, namely, a code of
federal regulations known as “42CFR Part 2,” prevents doctors from
sharing information about patients with substance use disorders unless that
patient gives the doctor written permission to do so.
42CFR Part 2 was originally conceived in 1972 as part of the Drug
Abuse Prevention, Treatment, and Rehabilitation Act to encourage
individuals with addictive disorders to seek treatment. This federal
regulation was important, effective, and compassionate jurisprudence at a
time when police enforcement was known to raid methadone maintenance
clinics and arrest individuals seeking help if they tested positive for illegal
drugs. Thirty years ago, 42CFR Part 2 was vital to protecting the rights of
individuals with addiction and ensuring their access to addiction treatment.
Transposed to the current day, however, especially with our reliance on
electronic medical records to coordinate and consolidate medical care, the
same statute impedes the integration of addiction treatment into the larger
health care system. As stated in a New England Journal of Medicine
commentary, these regulations “frustrate accountable care organizations and
health information exchanges, since their elaborate consent requirements
make it difficult or impossible to share patient data related to substance use
disorders. As a result, many organizations exclude such information from
their systems, undercutting efforts to improve care and efficiency.”143
The Centers for Medicare and Medicaid Services must redact all records
containing substance use treatment information of Medicare recipients,
about 20 percent of the Medicare population, when sharing patients’ data
with various accountable care organizations to facilitate care coordination.
Since 2015, half of the states in the United States have Medicaid Health
Homes, which serve millions of people, especially those with mental illness
and addiction. Prevalence of alcohol and opioid use disorders among
Medicaid Health Home recipients hovers around 80 percent. When
clinicians gather via conference calls to discuss individual patients to
coordinate and optimize their care, behavioral health professionals must
hang up when clinical substance use issues are discussed.
A doctor working inside a large managed health care organization
described a patient of hers who suffered dire consequences as a result of
42CFR Part 2. The patient was a high-functioning college professor who
drank on average a bottle of wine every night, more on weekends. She was
admitted to the medical unit of the hospital within the same health care
organization where she was being treated for her alcohol use problems, but
the doctors responsible for her medical admission did not have access to the
records describing her alcohol use. On admission to the hospital, the patient
herself may have minimized her use, presumably out of shame, or perhaps
her doctors failed to ask her about it, assuming a successful college
professor could not also be an alcoholic. Either way, several days into her
hospital stay, the patient developed fulminant life-threatening alcohol
withdrawal, an experience she survived, but not without complications. She
developed Wernicke’s encephalopathy and Korsakoff’s dementia as a result
of belatedly identified alcohol withdrawal. In other words, she incurred
irreversible brain damage because her treating doctors did not know that she
was at risk to go into alcohol withdrawal, and by the time they realized
what was happening, it was too late. Although 42 CFR Part 2 is waived in
cases of emergencies, lack of timely access to a patient’s substance use
history in the electronic medical record, particularly during a medical crisis,
limits the doctor’s ability to provide the best care.
42 CFR Part 2 as it currently stands has contributed to the prescription
drug epidemic by making it difficult if not impossible for doctors to tell
other doctors whether a patient is misusing or is addicted to the medications
they are prescribing. The result is doctors working at cross-purposes, with
addiction specialists trying to get patients off a medication, while other
doctors put them back on.

Doctors as Baristas
The current prescription drug epidemic is not the result of a small
population of deviant doctors willfully harming patients,144 although those
doctors exist. Rather, it is the result of a large population of well-intended
doctors working in health care factories that prioritize through-put of body
parts on an assembly line over whole-patient health. The result is
overprescribing, which is faster and better reimbursed than educating or
empathizing with patients. Pills that are addictive are particularly likely to
be overprescribed because they provide patient-customers with short-term
satisfaction and a proxy for human attachment—but not necessarily
improved health. When autonomy is truncated and professional status is
linked to earning power and patient satisfaction surveys, doctors are
vulnerable to objectifying patients as commodities rather than seeing them
as people. Patients are vulnerable to utilizing doctors as nothing more than a
source of drugs.
A San Francisco Emergency Department nurse was riding a public bus
to work in 2012 when she overheard the following conversation between
two women also riding the bus.
“What should we do today?” said the first.
“Not sure,” said the second.
“Well, we could go to Starbuck’s—or we could go to the emergency
room.”
They thought about it for a moment. Neither was in any apparent
medical distress. “Let’s go to the emergency room.”
And so it was decided.
We have arrived at an era when going to the emergency room for a shot
of Dilaudid (a highly potent opioid painkiller) or a few milligrams of
Klonopin (a benzodiazepine sedative) is pursued by some as casually as
ordering a shot of espresso. This scenario is the fault, not of the individuals
who seek out substances for nonmedical use, but of a system that has
allowed such a pursuit to be possible.
 9

Addiction, the Disease Insurance Companies Still

Won’t Pay Doctors to Treat

When Jim first walked through my office door in 2013, he said, “Doc, I’ve
got terrible pain, but I’m also addicted to painkillers, and right now my
addiction is worse than my pain.” His savings were gone, and his stamina
for manipulating ever-shadier doctors had run out. He briefly considered
getting heroin from a dealer, but he couldn’t reconcile that behavior with his
view of himself in the world. Heroin in particular represented a line he
wasn’t willing to cross (in contrast to the younger generation, for whom
there often is no line).
Jim was unusual in acknowledging both problems. Many patients who
become addicted to prescription drugs in a clinical setting are more
reluctant to accept the idea that addiction has taken hold in their lives. With
a narrative shaped in part by Alcoholics Anonymous, Jim already had a
framework for understanding what had happened to him.
The obstacle to his treatment was not his lack of insight into the need
for treatment. Indeed, contrary to popular belief that all addicted people are
in denial about their addiction, many people with drug and alcohol use
problems are well aware of their problem and desperate for treatment but
can’t get it because their insurance company won’t pay for it, and they don’t
have the resources to pay for it themselves. (Private residential
rehabilitation for addiction can cost upward of $50,000 per month.)
I prescribed Suboxone for Jim’s opioid addiction and referred him for
individual and group psychotherapy focused on addiction recovery. I also
urged him to renew his commitment to AA and be honest with his AA
sponsor about his addiction to prescription painkillers. Jim was more than
willing to follow my treatment recommendations. The problem? I couldn’t
get his insurance company to agree to pay for it.
 They first refused to approve the seven-day Suboxone prescription
unless I filled out three pages of paperwork justifying “medical necessity.”
Meanwhile Jim was experiencing painful opioid withdrawal, having
stopped using all opioid painkillers in anticipation of starting on Suboxone.
I filled out the paperwork and faxed it to the insurance company, only to
have it denied again because Jim had “chronic pain,” and Suboxone was not
FDA-approved for chronic pain. By this time I was on the phone yelling at
some hapless insurance company representative, demanding to speak to his
supervisor. “My patient has chronic pain and an opioid use disorder,” I said
through gritted teeth, “I am prescribing the Suboxone for his opioid use
disorder, and if you don’t approve this medication today, I will go to my
local newspaper and expose you for denying much needed medical care.”
They approved it, but the whole process required three days of back-
and-forth dithering, hours of my time away from clinical care, and raging
on the phone at someone I’d never met, not to mention the suffering Jim
endured at home vomiting in his bathroom. Suboxone is tightly regulated,
as it should be, because, as an opioid, it is potentially addictive. But had I
written a prescription for an opioid painkiller—like Vicodin, Fentanyl, or
OxyContin—Jim could have picked it up in the same hour. Barriers to
Suboxone prescribing stem not from its addictive potential but rather from
the consistent discrimination within the US health care system, and on the
part of insurance companies, against patients seeking treatment for
addiction.

A Brief History of the Disease Model of Addiction

The fight to get addiction recognized as a bona fide illness within the US
health care system, which coincides with getting insurance companies to
pay for its treatment, has been a long and often losing battle. Almost two
hundred years ago Dr. Benjamin Rush published An Inquiry into the Effects
of Ardent Spirits upon the Human Body and Mind: With an Account of the
Means of Preventing, and of the Remedies for Curing Them (1819),145 in
which he argued that chronic drunkenness is a biological disease, a radical
belief for its time. Most of his contemporaries still viewed excessive and
problematic substance use as a moral failing, a sin. Dr. Rush called for the
creation of “sober houses,” places where “confirmed drunkards” could
receive treatment. It wasn’t until 1864 that the New York State Inebriate
Asylum was opened in Binghamptom, New York, the first of its kind in the
country.146
Today, addiction affects 16 percent of the US population, about 40
million people, far exceeding the number of people afflicted with heart
disease (27 million), diabetes (26 million), or cancer (19 million). Disease
burden due to addiction exceeds half a trillion dollars annually. Yet in 2010,
only 1 percent of the total health care budget went to treating addiction.147
Even shifting public opinion on the cause of addiction has not managed
to revolutionize the medical approach. A survey conducted by the National
Center on Addiction and Substance Abuse (CASA) at Columbia University
found that two-thirds of Americans now believe that genetics and biological
factors play a role in the development of addiction, while a third continue to
view addiction as a lack of will power.147
Compounding the problem, doctors are not educated in the treatment of
addiction. Only 20–30 percent of primary care physicians feel “very
prepared” to detect risky substance use, yet 80 percent feel “very prepared”
to tackle hypertension or diabetes.147 Even psychiatrists are poorly trained
in screening and treating substance use disorders, and they often turn away
patients with addiction. Among practicing doctors, less than 1 percent
identify as addiction medicine specialists.147
Oddly, insurance companies have long been willing to provide
expensive, long-term treatment for other chronic illnesses, for example,
diabetes and kidney disease—including kidney dialysis, an expensive and
protracted intervention. Even other complex mental health issues are better
reimbursed than addiction treatment. Most insurance companies will now
pay for gender reassignment surgery for individuals diagnosed with gender
identity disorder, but they won’t pay for emergent inpatient treatment for
someone in acute opioid withdrawal.
Yet we know that with medical treatment, addiction behaves very
similarly to other chronic illnesses with a behavioral component, such as
type II diabetes (behaviors related to diet), including similar rates of
compliance with treatment, remission, and relapse.148 Individuals who
actively engage in treatment for addiction have, on average, a 50 percent
recovery rate,106 which is on par with response rates for other mental health
conditions, such as depression and schizophrenia, and at odds with what
many people assume about addiction treatment—that it is hopeless. These
data lend support to the argument that addiction can and should be managed
within the health care system.
The passage of the Paul Wellstone and Pete Domenici Mental Health
Parity and Addiction Equity Act (MHPAEA), signed into law in 2008,
requires group health plans that offer mental health or substance use
benefits to offer them at parity with medical and surgical benefits. The
passage of the Affordable Care Act expands this protection to an additional
estimated 62 million Americans. Yet insurance companies still do not
reimburse for addiction treatment on a par with other medical illnesses,
finding loopholes and work-arounds to deny care. There continues to be
widespread discrimination in health plans against those with mental health
or substance use disorders.
As long as the US health care system ignores addiction, it will be
burdened with paying for the costly treatment of the downstream medical
consequences of addiction, never getting to the root cause, and millions of
Americans will continue to suffer. For every dollar the federal and state
governments spend on addiction, ninety-five cents goes toward treating the
medical consequences of addiction, and only two cents goes toward
addiction prevention and treatment.147 Prescription drug misuse and
addiction is one of these many downstream consequences.
My patient Diana’s life story is illustrative of the serious health
consequences that ensue when a patient is treated in a health care system
that does not teach or reimburse its doctors to recognize and treat addiction.
Diana’s story also exemplifies the chronic, relapsing, and remitting nature
of addiction.

The Many Faces of Addiction

When Diana was just two-and-a-half years old, her mother was pushing her
in the stroller down the aisle at Mervyn’s department store when she saw a
set of clown-face hair clips and decided she had to have them. She reached
out to grab them, but her mother stayed her hand. Diana’s mother had
always been particular about what Diana wore, and she was not inclined to
buy the clown clips.
 In response to being denied what she wanted, Diana did not make a
pouty face, whine, or cry. She screamed. She screamed again and again,
with such intensity that people shopping in the aisle raised their heads in
alarm. When they looked in the direction of the screams, they saw a pretty
little girl sitting in a stroller, her head thrown back, her face in a distorted
grimace, her legs kicking out at the air, and her mother, panicked and
helpless in the face of her daughter’s ferocious desire.23–26
Her mother hurried her out of the store and wrestled her into the car
seat, Diana wailing and arching her back in protest all the while. Two hours
after they arrived home, Diana was still screaming when her mother called
her husband in desperation, asking him to come home from work and help
her. When Diana’s father arrived home, he put Diana, still crying, into his
car, and drove for hours. This would be the first of many such drives to
calm Diana down. Finally, Diana cried herself to sleep. When her father
arrived back home, he gently transferred Diana from the car to her bed. As
he was tucking her in, he noticed her little fist tightly gripping an object. He
gently peeled back her fingers, one by one, careful not to wake her. There,
in Diana’s hand, were the clown-face hair clips.
From very early in her life, whatever emotions Diana experienced, she
experienced with above-average intensity, chronicity, and duration, and she
seemed literally incapable at times of moving past it. She also demonstrated
a reflexive response to her in-the-moment desires, acting on those desires
with such willfulness that she was unable to logically weigh the pros and
cons of her behavior.
When Diana was 11 years old, her uncle called her “chubby”—just an
innocent observation, made in passing—but she couldn’t stop thinking
about it, and kept comparing her budding, early adolescent body to the
images of perfection she saw in fashion magazines. She was determined to
get thin, but didn’t want to deprive herself of the foods she liked to eat.
Then she had an idea.
She sat in the dark, alone, at the top of the stairs, waiting for her parents
and her older brother to go to sleep. It was midnight before her parents’
bedroom light finally went out. She slipped downstairs, taking the steps one
at a time, careful not to make a sound. She opened the refrigerator, the light
from inside cutting across the darkness of the room. She took out the pasta
dish with the creamy clam sauce, the one she had allowed herself only a
few bites of at dinner. She ate it right from the serving dish, quickly, taking
in three or four regular-size portions at once, until her belly felt too full to
continue. She didn’t worry though, because in her mind the calories
wouldn’t count. Less than five minutes later she was in her bathroom
upstairs, behind a locked door, leaning over the toilet with her fingers down
her throat.
Diana was 14 years old when her parents discovered her behavior, and
by then she was making herself vomit every day, sometimes more than once
a day. They moved into high gear, getting her a doctor, a counselor, a
nutritionist. She did individual therapy, family therapy, group therapy. Her
parents carefully monitored everything she ate. But even with all that
intervention, it was hard for Diana to stop. Even she was surprised by how
hard it was. She had long ago achieved the body she wanted, so for her, it
was no longer about being thin. Instead, she found herself craving the
release of tension that making herself vomit gave her. Sometimes she would
binge and purge twice in a row, in order to extend the feeling. Years later,
she would reflect, “A lot like my heroin addiction, bulimia was that same
pattern of having this secret space that no one else knows about where you
do this disgusting activity. Once you’re doing it, once you’re in it, you lose
the meaning of why.”
For decades the field of psychiatry has conceptualized bulimia nervosa
as an eating disorder, defined by the ingestion of large amounts of food
followed by purging that food, most commonly through self-induced
vomiting. More recently, however, clinicians and scientists are comparing
bulimia to addiction. Thirty to 50 percent of individuals with bulimia have
an active drug or alcohol use disorder, compared with approximately 9–15
percent in the general population, and up to 35 percent of individuals who
have an alcohol or drug use disorder also have an eating disorder, compared
with about 1.6 percent in the general population. These high rates of co-
occurrence provide some indirect evidence for a shared disease pathway.149
Even more compelling is how the specific eating patterns seen in bulimia
are particularly addictive and differentiate bulimia from eating disorders
such as anorexia. Bingeing on food, particularly foods high in sugar,
releases dopamine in the brain’s reward pathway, similar to the mechanism
of action of drugs of abuse.150 The vomiting that follows acutely increases
endorphins, the body’s own heroin, to augment the increased extracellular
dopamine.151
 In 1995, when Diana turned 15, her parents sent her to one of the most
elite private high schools in Silicon Valley. Her bulimia was improving, and
they were determined that her future would be bright. Diana remembers
spending most of her first few weeks at school figuring out who the popular
kids were and how to be a part of their group. Like herself, many of her
classmates were the children of aging hippies. “Fleetwood Mac’s niece was
there!” But unlike Diana, they were worldly in a way that was foreign to
her. And they used drugs. In an effort to fit in, Diana began smoking
cigarettes. They laughed when she choked on her first puff. From cigarettes
she quickly progressed to alcohol and marijuana, providing another
example of “neighborhood” as a risk factor for addiction, in particular
exposure to drug use at school.

Alternative Rewards Reduce Substance Use

At age 16, Diana had an epiphany. She decided she wanted to be an artist.
She made a conscious decision to cut back on alcohol and drugs, get a job,
save her money, and go to art school. With this goal in mind, she graduated
from high school at 17, rented an apartment in San Francisco, and went to a
fashion institute. She had some early modest success, with her own art
show, a publication in a San Francisco fashion magazine, and a nomination
for a fashion photography award. Her drug and alcohol use during these
years was intermittent.
Diana’s ability to curtail drug and alcohol use during this time speaks to
the importance of alternative rewards—including even the promise of future
reward—when trying to limit substance use. As Charles Duhigg describes
so well in his book The Power of Habit,152 to change deeply ingrained
behavior, the individual must find a way to substitute a new reward for the
old reward. The same phenomenon holds true for rats. If you put a rat in a
cage with nothing to do but press a lever for cocaine, it will develop all the
major behavioral signs of cocaine addiction. However, if you add another
lever the rat can press for a sugary drink, or a wheel the rat can run around
on for fun, then the likelihood of that rat becoming addicted to cocaine is
much less, and a rat who is already addicted to cocaine will use less
cocaine.153, 154 For Diana, the accolades she received from her artwork
helped curb her substance use.
 Heroin Chic
By the time Diana was 20, she was solidifying her identity as an artist, and
she decided that the next step for her was to move to New York. With
financial help from her parents, she moved to Manhattan. The late 1990s
was the height of “heroin chic” in Manhattan, when scantily clad emaciated
young women with dark rings under their eyes represented the pinnacle of
beauty. Life-sized posters of Kate Moss, the “it-model” of the decade,
papered the streets of all five boroughs of the city, often defaced with the
words “feed me” scrawled across Kate’s skeletal figure.
Diana, an uncommonly pretty girl, with long brown hair, big brown
eyes, and delicate bones, fit right in. She worked as a model but tried to
establish herself primarily as a fashion designer and photographer. With her
looks, as well as the fact that she came from money, Diana quickly
insinuated herself into the upper echelons of the New York fashion world. It
didn’t take her long to discover that drugs and alcohol were an inherent part
of that world.
Diana spent hours, and sometimes days, planning what she would wear
for an evening out. She might visit vintage shops, or create a “mood board,”
to generate ideas for an outfit. Her date, often an older man of means,
would pick her up around 6 pm, and together they would go to New York’s
meat-packing district, the heart of the art scene, where blocks of art
galleries hosted openings, followed inevitably by the after-party.
Every evening out would begin with alcohol, wine, or champagne
served in tall fluted glasses passed around on trays. Diana drank eagerly. “If
I saw David Bowie—or Mick Jagger, I wanted to be ready. I didn’t want to
be star-struck.” For Diana, these evenings out were not just leisure; they
were essential to her craft. She was there in part to find out what other
people were doing and to generate ideas, digest them, and re-create them in
another form. The ideas came not just from the art on the walls but also
from the people she saw, the clothes, the gossip. The sense of urgency was
palpable, and relentless.
Dinner didn’t happen until after nine, and by then Diana was exhausted
and not a little drunk. That’s where cocaine came in. Diana remembers that
getting cocaine at a party in Manhattan was as easy as ordering pizza.
Someone would just call a number—everybody knew a number—and drugs
would be delivered to the door. Diana prided herself on never being the one
to order drugs or pay for them, something, she told herself, “only addicts
did.” They were always given to her as a gift. She would go into the
bathroom and line the cocaine up in neat rows on the lid of the toilet seat.
Kneeling down delicately, she would snort the lines, one nostril at a time.
Again, the bathroom was a familiar sanctuary, which perhaps should have
been a warning sign. Still, Diana was busy learning her craft and
collaborating with other photographers and fashion designers. She could go
days at a time without using any drugs. All that changed after she tried
heroin for the first time.
It was 2001. Diana had just turned 21, and the specter of the Twin
Towers bombing was still months away. She went to a friend’s apartment to
do a photo shoot. The friend was a model, and they often collaborated on
projects. Her friend ordered heroin and had it delivered to the apartment.
She put the soft white powder on the back of a CD case, snorted it, and
offered Diana some. Diana snorted one-fifth of a line and felt its effects
instantly. The first thing she noticed was that “the noise was gone.” The
cacophony of her New York City lifestyle was now only a distant hum.
More importantly, the relentless muttering of her own inner voice, mostly
telling her she was no good, was also silenced. It wasn’t euphoria she felt as
much as a sense of relief at not having to feel. She also felt nauseated and
ran to the bathroom to vomit. After vomiting, her very next thought was a
certainty that she would do heroin again. “It was magical.”
Heroin possession and distribution is illegal in the United States, but
heroin is readily available on the black market, sold as white or brownish
powder mixed with powdered milk, starch, sugars, or quinine. “Black tar”
heroin is sticky like roofing tar, mostly produced in Mexico, and
predominates in markets west of the Mississippi, for example, in California.
The dark color results from the processing method, which leaves behind
impurities. Black tar heroin must be dissolved, diluted, and injected into
veins, muscles, or under the skin. In its pure form, heroin is a white powder
with a bitter taste, usually from South America. It dominates US markets
east of the Mississippi, for example, in New York. Pure heroin can be
snorted and smoked as well as injected. Once heroin enters the brain, it is
converted to morphine, leading to an immediate rush.
Since coming to New York City, Diana had bought no drugs for herself,
but she immediately began buying heroin. Using just a little each day, she
made her first $50 purchase last for two to three weeks. When she had used
it all up, she experienced nausea, vomiting, diarrhea, and muscle cramps.
She assumed she had the flu, not realizing that she was in opioid
withdrawal. Within a few months, Diana had progressed to a $100 a day
habit, and she started getting a reputation as a “junkie.” Using drugs was
accepted in New York’s glamorous world of fashion, but being a junkie was
not. When the Twin Towers fell on September 11, 2001, she was so busy
fashioning a line of white powder on a clean glass surface that she hardly
noticed.
By 2003 Diana’s life had completely unraveled. Her career in fashion
photography was nonexistent, many of her friends had abandoned her, and
her money was gone. So she left New York for California, hoping that a
change in location would allow her to start over again. She went to private
rehabs in California, paid for by her parents. Her medical insurance covered
nothing. Despite private treatment, she kept relapsing. At her lowest point,
she was living in a seedy apartment in San Francisco, paying weekly rent
from the money she earned as a stripper, using the leftover cash to support
not just her heroin addiction but also the habit of the boyfriend living with
her, whom she’d met on the street buying drugs.

Medical Complications of Addiction—a Revolving

Door
In 2005, when Diana was 24 years old, she developed pustular nodules on
her skin as a result of having injected heroin for four years. The nodules
quickly transformed into large red swollen patches all over her body. She
also had difficulty breathing. Her father rushed her to the emergency room.
Electronic medical records from Diana’s first hospital admission
describe her left arm as covered with “swollen, pustular vesicles . . .
draining fluid” with areas of skin that felt as if there were “cobblestones
underneath.” Her right arm was afflicted, as was the base of her right
thumb. On her right ankle, she had a 4 cm cyst filled with blood and pus.
The inner side of her left calf had a 2 x 2 cm open wound draining bloody
purulent fluid. A chest X-ray revealed pneumonia, with possible infected
heart valves. Cultures of her wounds were positive for the bacteria
Staphylococcus aureus, a particularly virulent form resistant to the
antibiotic Methicillin, and therefore known as MRSA—Methicillin-resistant
Staphylococcus aureus.
She was diagnosed with severe MRSA furunculosis, MRSA bacteremia,
cellulitis, and skin abscesses. The differential diagnosis at the time of
admission included rare immune deficiency syndromes such as Hyper IgE
Syndrome and Job’s Syndrome. It wasn’t till days after admission that her
doctors asked her about intravenous drug use, which, according to the
medical record, she initially denied. Collateral information obtained from
her parents led to documentation of a clear history of heroin addiction,
including intravenous use.
The medical consequences of heroin use, in particular intravenous
heroin use, are many, and depending on route of administration, include but
are not limited to constipation, pneumonia, tuberculosis, damage to mucosal
membranes from snorting, perforated nasal septum, scarred or collapsed
veins, bacterial infections of blood vessels and heart valves, abscesses and
other soft tissue infections, hepatitis, HIV, and accidental overdose by
slowing heart rate and depressing respirations.
Diana’s treatment, which saved her life, included six different
intravenous antibiotics, surgical drainage of her abscesses, and multiple
skin grafts. For pain control she was given a long-acting form of morphine
sulfate (MS Contin), 90 mg three times a day, dissolvable oral morphine, 50
mg every two hours as needed for pain, and intravenous fentanyl (another
potent opioid), 100 mcg prior to every dressing change, which occurred two
to three times per day. Diana was in the hospital for weeks, and as a
necessary condition of her treatment, her brain was bathed in opioids the
entire time. At the time of discharge, Diana’s doctors were in general
agreement that her infection and ensuing medical problems were the
downstream result of her intravenous drug habit. Despite this awareness, no
part of her otherwise very thorough discharge planning involved any
recommendation or referral to addiction treatment. In a system in which
doctors are not educated to recognize addiction as a disease, or paid by
insurance companies or other third-party payers to treat addiction, it is
logical that Diana’s doctors ignored it.
Diana was sent home with an intense regimen of medications and
treatments for her wounds and residual infection. She had a peripherally
inserted central catheter (PICC) in her arm so that she could continue to
receive intravenous antibiotics even after discharge. She was given follow-
up appointments at the infectious disease clinic, the hand clinic, the pain
clinic, the immunology clinic, the primary care clinic, and twice daily
appointments at the ambulatory care clinic to receive an infusion of
Vancomycin (an antibiotic) and dressing changes. She continued to receive
MS Contin 90 mg three times daily after discharge, as well as fast-acting
dissolvable tablets of morphine 60 mg every two hours as needed for pain,
and 90 mg of the same prior to dressing changes, which occurred twice
daily.
In the months that followed Diana’s first hospital admission, as her
wounds began to heal, her doctors attempted to reduce the opioids she was
taking for pain. Not surprisingly, every attempt to reduce her opioids was
unsuccessful. In response to her inability to comply with their
recommended reductions, Diana’s doctors refused to prescribe opioids any
longer. Diana went from a steady high dose of prescription opioids,
supplied by her physicians, to zero. Diana, no stranger to opioid withdrawal
at this point in her life, briefly considered using heroin again but was
terrified of recurrent infection. Instead, she found another solution.
With the sustained-release morphine sulfate pills she had left, she took a
small pair of scissors and scraped the time-release coating off of the outer
portion of the pill. She crushed it with a mortar and pestle down to a fine
powder. She mixed the powder with the saline she’d been given by the
doctors to flush out her PICC line and injected it intravenously through the
PICC line. By changing the route of administration, she was able to
increase the bioavailability of the pills she had left and thereby extend her
supply. Diana’s story mirrors that of other injection drug users in the late
1990s early 2000s, who switched from IV heroin to prescription opioids
with the increased availability of the latter.155, 156
Given the absence of medical treatment for her addictive disorder, it
was no surprise that Diana was unable to stop using opioids. Data show that
untreated opioid addiction is characterized by relapse, noncompliance with
medical treatment, and increased morbidity and mortality.148 For the next
three months Diana continued shooting up dissolved MS Contin from her
leftover stash. In January 2006, Diana’s mother walked in on her shooting
crushed morphine into her PICC line and called the police.
 The police put Diana on a legal hold called a “51-50,” which allows a
doctor to admit an individual against his or her will to a psychiatric ward
for observation and treatment for seventy-two hours. Admitted to the same
hospital where she had received her original treatment, Diana was now on
the psychiatric unit rather than the medical unit. On the psychiatric unit,
more than six months after she had been admitted to the hospital for the
first time, Diana was at last formally diagnosed in the electronic medical
record as having a drug addiction, or in the language of the latest
Diagnostic and Statistical Manual of Mental Disorders (5th ed.), an “opioid
use disorder.”15
Physicians seldom officially diagnose and document a substance use
disorder in the electronic health records (EHRs), even when they agree that
a substance use disorder exists. Electronic health records have primarily
become a means of justifying billing to third-party payers, that is, Medicare,
Medicaid, and private insurance companies, rather than a record for
documenting illness and its treatment.157 Since doctors don’t get paid to
treat addiction, there’s no reason to put it in the record. Some doctors also
fear that the label will stigmatize patients and compromise their future care.
More often, however, it’s the lack of information on patients’ substance use
in the medical record that compromises their care.
Diana entered a residential addiction treatment center after her
discharge. This treatment center cost her family tens of thousands of dollars
for a thirty-day stay. Fortunately, they were able to afford it. Her care in the
treatment center, which included treatment with Suboxone, allowed her to
stop using opioids in one form or another for the first time in many years.

Benzodiazepines—the Hidden Prescription Drug

Epidemic
Diana began seeing a psychiatrist after she was discharged from the hospital
in 2005. Her psychiatrist added one psychotropic medication after another
—antidepressants, mood stabilizers, anxiolytics, hypnotics—until she was
taking upward of fifteen pills each day. Despite the hospital
recommendations not to resume any benzodiazepines or other potentially
addictive sedative hypnotics, Diana’s psychiatrist initiated her on a course
of the benzodiazepine Valium.
The first benzodiazepine, Librium, was synthesized accidentally by Leo
Sternbach in 1955 and then marketed for the treatment of anxiety and sleep
disruption by the pharmaceutical giant Hoffmann La Roche in 1960. The
market success of Librium inspired the company to create another
benzodiazepine, which they did with the synthesis of Valium in 1963.
Valium was a best-selling drug for La Roche, the first to reach $1 billion in
sales, and became the most widely prescribed drug for anxiety in the world.
It also captured the American imagination, memorialized in the 1966
Rolling Stones hit “Mother’s Little Helper.”
Today, doctors’ prescriptions for benzodiazepines continue to rise, and
are a major culprit in the epidemic of prescription overdose deaths plaguing
this country. Nonetheless, benzodiazepines are relatively ignored in the
national discussion on rising rates of addiction. Many doctors are
prescribing benzodiazepines to help patients get off of opioid painkillers,
without recognizing or understanding that benzodiazepines themselves are
highly addictive.
Diana started at a low dose of Valium, only 10 mg daily, but progressed
to 10 mg twice a day, and in the weeks that followed quickly escalated to
more than 100 mg daily, all prescribed by her psychiatrist. She did not do
well. She lived with one or the other of her parents, was not able to
maintain any kind of consistent employment, and was not able to engage in
any of the artistic endeavors that had previously sustained her. Her
psychiatrist diagnosed her with bipolar disorder, which she never felt fit her
issues but which legitimized the federally funded disability check she got
every month, the multitude of psychotropic medications she was on, and the
monthly private-pay appointments. Between 2005 and 2013, she was
essentially an invalid.

Addicted to Being a Patient

When Diana first came to my clinic in 2013, she did not self-identify as a
person with addiction. She hadn’t used heroin in years. But she was on a
dizzying list of psychotropic medications, including Xanax to calm her
down, Ritalin to pump her up, Depakote to even her out, Prozac to make her
happy, and Ambien to put her to sleep. She was also using “medical
marijuana” two to three times a day. Despite all these medications, she was
anxious, distractible, emotionally incontinent, depressed, and unable to
sleep.
In retrospect, of that particular moment in her life when she was taking
fifteen or more pills and smoking cigarettes and marijuana daily, Diana
would say, “I lost my voice. I was like one of those Victorian women
diagnosed with hysteria and given laudanum. My doctor even told me I was
a hysteric. I’d stopped using heroin, but I was a drug addict as much as
ever. When I finally told my doctor I wanted to get off all the drugs and
move ahead with my life, he told me I couldn’t. He told me I was too sick,
and I’d be sick forever.”
Diana was admitted to the voluntary psychiatric unit that week and
taken off all psychotropic medications except Suboxone, the only
medication that consistently improved her function. When she was
discharged this time, she went to weekly group therapy sessions focused on
addiction recovery. She got a part-time job caring for her maternal
grandmother, who was struggling with end-stage Alzheimer’s. Most
importantly, she got her brain back. She could think again.
A year after being discharged from the hospital, life is not easy for
Diana. She continues to struggle with wide mood fluctuations and fits of
rage, directed at those who care about her most. But she is not using heroin
or any other illicit drugs. She even quit smoking cigarettes and marijuana.
Sitting in group therapy, wearing faded jeans and a peasant blouse, twisting
her long thick hair, she said, “For years I was a heroin junkie, and then I
became a patient junkie, addicted to prescription drugs as much as I was
ever addicted to heroin—maybe worse. But I got tired of being a junkie,
and I got tired of being a patient. I help take care of my Grandma now. She
has Alzheimer’s, and I do a lot of things for her, just like taking care of a
little baby. My mom says I take even better care of her than she does.” With
that she stops twirling her hair for a moment and smiles. “I want to be well,
and hold on to my dignity as long as I can. I can think again, and I’m doing
art again, and that feels really good.”
Diana’s story, from the toddler who demanded clown hair clips, to the
“heroin junkie,” to the young woman taking a fistful of prescription pills
every day, illustrates the chronic relapsing and remitting nature of addiction
and thus the need for a chronic-care model to treat it. It also highlights the
profound ignorance of doctors, including even psychiatrists, who are
supposed to be experts in mental illness, when it comes to detecting,
diagnosing, and treating addiction. Diana’s story, and Jim’s, demonstrates
how parity still does not exist within the US health care system for the
treatment and reimbursement of addictive disorders.
 10

Stopping the Cycle of Compulsive Prescribing

Jim did well with treatment for almost a year, abstaining from opioid
painkillers and other addictive substance use during that time. What
precipitated his relapse in the end was nothing dramatic or even particularly
memorable. His insurance changed. The cab company opted for a new
health insurance plan for its workers, and that plan did not cover my clinic.
Jim couldn’t find an addiction specialist in-network with his new plan
(there aren’t many of us), so he started over with a new primary care doctor.
My last conversation with Jim was by phone in 2014, when I called him
to check in.
“How’s it going, Jim? How are you doing?”
“I’m okay, doctor. I think I’m okay. But I had to stop the Suboxone,
because, you know, I couldn’t find anyone to prescribe it. And then my new
doctor, she put me back on Norco for my back pain.”
“But did you tell her about your history?” I asked.
“I told her about the alcohol, but not, er, the pills . . .”
“Jim . . . why not?”
“Because I really think I can handle it this time, Doc. I really think I
can. And the Norco works better for my pain. Maybe I’m headed down the
wrong road . . . I’m probably headed down the wrong road . . . but for right
now, this is what I gotta do.”
“Would you like me to call your new doctor and talk to her about your
situation?”
“No, Doctor, thank-you, but that won’t be necessary.”
“Are you sure?”
“Yeah, I’m sure.”
Awkward pause. “Okay Jim, take care of yourself. Let me know if . . .
you know . . . later, I can help.”
 “I will, Doctor. I promise I will.”
I’ve not heard from Jim since. Jim, wherever you are, I hope you’re
okay.

Despite Policy Changes, the Epidemic Rages On

Since the CDC first declared a state of emergency around prescription drug
addiction and overdose deaths in 2011, much has been done at the federal,
state, and local levels to target the problem. Naloxone, a medication that
can counteract a lethal opioid overdose, has been approved by the FDA, and
Good Samaritan laws in many states now give doctors the ability to
prescribe naloxone to patients, their friends, family members, or anyone
who might witness and seek to prevent an opioid overdose.158 Prescription
drug–monitoring databases, which allow a doctor to check all the
prescriptions a patient has received for controlled substances, have been
implemented or invigorated in every state.131 Hospitals, emergency rooms,
and clinics across the country have created policies to limit opioid
prescribing. Educational campaigns and guidelines on safe opioid
prescribing have been launched. New prescribing guidelines now warn
doctors of the risk of addiction to opioid painkillers. (Most of the
interventions have targeted opioid painkillers. By contrast, almost nothing
has been done to curb the more silent epidemics of stimulant [Adderall] and
sedative-hypnotic [Xanax] overprescribing, misuse, and addiction.)
Despite these interventions, the prescription drug problem continues.
From 2000 to 2014, almost half a million Americans died from drug
overdoses. Opioid overdose deaths, including opioid painkillers and heroin,
were the biggest driver behind these deaths, reaching record levels in 2014,
with a 14 percent increase in just one year.159 More than 200 million
prescriptions for opioid painkillers continue to be written by US doctors
every year.
Indeed, the prescription drug epidemic is likely to continue for the
foreseeable future unless we do more to target the unseen forces driving the
epidemic. (Even public discussion of these unseen forces verges on political
incorrectness.) Cultural narratives promote pills as quick fixes for pain.
Corporations in cahoots with organized medicine misrepresent medical
science to promote pill-taking. Medical disability hinges on patients taking
pills and staying sick as a way to secure an income. A new medical
bureaucracy is focused on the bottom line, favoring pills, procedures, and
patient satisfaction over patients getting well. And disjointed medical care
and antiquated privacy laws make it impossible for the right hand to know
what the left hand is prescribing.
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.

How Can We End This Cycle of Compulsive

Prescribing?
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. A little
over a century ago, caring for the poor, the homeless, the unemployed, and
the addicted fell to religious organizations. With the secularization of
society in the early 1900s and the medicalization of many aspects of
everyday life in the latter half of the twentieth century, doctors are now
responsible for many more aspects of their patients’ lives than what has
traditionally been thought of as “disease.” But, like trying to fit a too-large
foot into a too-narrow shoe, doctors must “pretend” that their patients’
problems are purely medical in order to shoehorn them into our current
industrialized, fee-for-service, assembly-line health care system.
In order to address this mismatch, we as a society must restructure the
health care system to openly acknowledge the new mandate for medicine to
care not just for those with physical illness but also for those with mental
illness, including addiction. We must build a medical infrastructure that
targets the problems people have, not assigns them problems they don’t
have to justify services within the existing system.*
Complex mental and behavioral problems require long-term care and
the healing that is borne of relationship and community. Their treatment
demands seamless integration with the rest of medicine, not the
marginalized status they currently hold. Medicine must once and for all
embrace addiction as a disease, not because science argues for it, but
because it is practical to do so. As long as the system continues to ostracize
patients with addiction, especially while openly embracing and aggressively
treating disorders such as chronic pain, chronic fatigue, fibromyalgia,
depression, attention deficit disorder, and so on, the prescription drug
epidemic will continue, as will the suffering of millions of people with
untreated addiction.
In order to accomplish this goal, addiction treatment needs to be taught
at all levels of medical education. Currently addiction is a very small part of
most medical school curricula and is absent from almost all residency
training programs, including many psychiatry residencies. Medicine is
learned through a series of apprenticeships. Residency lays the foundation
for how doctors will practice medicine for the rest of their lives. Until
training in addiction medicine permeates medical school and residency, the
physician workforce will remain unskilled. One way to do this is to link
federal funds currently used to subsidize medical school and residency
training programs to mandatory inclusion of addiction medicine content.
Newly created addiction medicine fellowships represent progress
toward this goal. These are fellowships that offer in-depth training in
addiction medicine open to any doctor who has completed a residency in
any clinical medical specialty, from trauma surgeons to anesthesiologists to
primary care doctors.160 The addiction medicine fellowships should be
expanded and given better funding, and residents should be encouraged to
participate in them.
The expanding medical workforce, including nurse practitioners and
physician assistants, who in many states function de facto as doctors, must
also be trained in addiction medicine. An analysis of Medicare prescribers
in 2013 determined which medical specialties, based on sheer volume, were
prescribing the most opioid painkillers. Family medicine was first, with
15,312,091 prescriptions in one year, followed by internal medicine, with
12,785,839 prescriptions. Nurse practitioners were third, accounting for
4,081,282 prescriptions, and physician assistants were fourth, with
3,089,022 prescriptions.144 We clearly cannot, nor should we, ignore this
influential and growing cadre of health care professionals.
Addiction treatment must be delivered in a chronic care model that
prioritizes the importance of the doctor-patient relationship and the
therapeutic environment. Doctors must be reimbursed not only for
prescribing medications but also for talking to and educating their patients.
This requires more time with patients than doctors in most health care
organizations are currently granted. Time with patients is the essential
precursor for empathic listening, informed judgment, and the healing power
of human connection. The question is how to accomplish this.

New Models for Care

In 2010 the Kaiser Permanente Medical Group in Northern California
recognized that there were opportunities to improve care for their patients
dealing with chronic pain. Each separate Kaiser facility was encouraged to
develop new programs that might better serve patients and improve patient
outcomes.
Karen Peters, a clinical psychologist working at Kaiser Santa Clara’s
Chemical Dependency and Rehabilitation Program, and Barbara Gawehn, a
registered nurse working in Kaiser Santa Clara’s Chronic Pain Program, got
together as part of a larger team to reimagine what a better pain program
would look like, and how they might accomplish it. Both Karen and Barb
had already been working together at Kaiser as part of an opioid taper
program, and they were well acquainted with the phenomena of prescription
opioid misuse, tolerance, dependence, and addiction. They also noted that
once the opioid taper was complete and acute withdrawal symptoms were
over, the patients actually had less pain than they had while on opioids.
Being off the drugs made their pain better.
Karen, Barb, and their team decided that their new pain program would
use nonpharmacological methods to target pain. In order to do this, they
believed patients would have to be off opioids and other mind-altering
medications, including “medical marijuana,” which might cloud their
ability to learn the techniques they were planning to teach, including
mindfulness meditation. Therefore, any patients entering their program
would have to be willing to taper down and off opioids, a process the team
would facilitate.
They realized such a program would necessitate daily visits, at least
initially, to provide the necessary psychosocial support for patients in opioid
withdrawal and struggling with pain without opioid painkillers. They
planned to administer all treatment, including psychotherapy and physical
therapy, in groups, because building a supportive community between
patients was at the heart of their new approach. As Karen said, “I knew in
my gut that a therapeutic community would be the vehicle for change,
would be the provider, in essence.” This idea of the group itself as the
vehicle for recovery is deeply rooted in the philosophy of Alcoholics
Anonymous and other mutual-help recovery groups. The main difference
here was that the providers would be integrated into the community and
would practice the interventions alongside the patients.
The program they created, which got under way in 2011, is little
changed from the program that continues to this day. In the first phase,
which lasts three weeks, patients come every day. In the second phase,
which lasts three weeks, they come three times a week. In the third and
final phase, which lasts at least a year but can go on indefinitely if patients
choose to continue, patients are offered a menu of activities up to three days
a week. Every day the program begins with every provider, including the
doctors and every patient in the room, participating together in a series of
activities that serve to teach and heal patients and also to build community
—mindfulness meditation, chi gong, yoga, educational seminars, cognitive
behavioral therapy, Feldenkrais, and even physical therapy. By sharing a
common experience, patients and providers together build a common
language, one that serves to shape an illness narrative, the core of which is
that they need to “retrain their nervous system” to find a different way to
manage pain.
Kaiser Santa Clara has now shepherded hundreds of patients through its
Pain Management Rehabilitation Program, with remarkable transformations
in the individual lives of many who have participated. Patients who were
nonfunctional due to pain and lived hour to hour anticipating their next pain
pill are now free of opioids and other addictive drugs and reengaged in their
lives. This program serves as a potential model for how to help patients heal
from chronic biopsychosocial disorders, including addiction and chronic
pain.

A Clarion Call for Change

Understanding and ending the prescription drug epidemic is vital for all of
us—doctors, patients, and their loved ones. People are dying every day
from the adverse medical consequences associated with prescription drugs.
Even absent harm to patients, doctors have an ethical responsibility to
prescribe safely and judiciously and to stop prescribing when the risks of
the drug overpower any foreseeable benefit. Patients have a right to quality
care, even if it’s not the care they think they need. The most valuable
commodity each doctor has is his or her relationship with the patient. It’s
time to rethink how medicine is delivered, in order to preserve this central
truth. The prescription drug epidemic is a symptom of a faltering system, a
clarion call for change, not just for patients who have become addicted to
prescription drugs, but for all patients and the doctors who treat them.
*
The alternative is to decide that the medical system is not the appropriate venue to target
poverty, unemployment, isolation, family dysfunction, etc., and to create social services outside of
medicine which can do it better.
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 Index

AA (Alcoholics Anonymous), 13, 18–19, 99–100

academic physicians, role of, in epidemic, 57–62
ADD (attention deficit disorder), 45–46, 49
Adderall, 45–46, 49–52
addiction: to benzodiazepines, 145–46
bulimia and, 137
consequences of, 14, 134–35, 142–45
diagnostic criteria for, 14
drug-seeking patients and, 79–80
eating disorders and, 137
gateway hypothesis of, 22–23
to heroin, 30–33
Portenoy on rates of, 61
recovery from, 18–19, 134
reward circuitry of brain and, 15, 22, 137
risk for, 16–18, 24, 95–97, 138
sharing of information about, 126–27
terminology, xi, 14n. See also addiction treatment; models of addiction;
opioid addiction; substance use disorder; withdrawal
addiction treatment: chronic care model of, 153–54
Drug Addiction Treatment Act, 84
insurance companies and, 131–32, 134
training in, 152–53
adolescents. See teens and prescription drugs
advertising, direct-to-consumer, 58n
Affordable Care Act, 134
Alcoholics Anonymous (AA), 13, 18–19, 99–100
alcohol withdrawal, 127–28
alternative rewards, as reducing substance use, 138
American Academy of Pain Medicine, 63
American Pain Foundation, 62–63
American Pain Society, 63
antidepressants, for adults, 48
anxiety, and defense mechanisms, 106–8
“Art of Distraction, The” (Kureishi), 50
assessment of pain, 66
attention deficit disorder (ADD), 45–46, 49
autism spectrum disorders, 98
autobiographical narratives, 39–40
Autor, David, 91, 92, 101
Axelrod, Robert, 87

BAART (Bay Area Addiction Research and Treatment), 33

backward logic in mental health care field, 46
benzodiazepines: addiction to, 145–46
combination of opioids and, 4
as schedule IV drugs, 6
Bergman v. Eden Medical Center, 64
best practices, 65–66
Big Medicine, role of, in epidemic: academic physicians, 57–62
FDA, 67–71
Federation of State Medical Boards, 64–65
professional medical societies, 62–64
Big Pharma: academic physicians and, 58–62
class actions suits against, 71
FDA and, 68
JCAHO and, 67
opioid epidemic and, 57
“pain management educational program” for hospitals and, 66–67
perks given to doctors by, 57–58
professional medical societies and, 62–63
brain pathology, individual difference as, 43–49
Bruner, Jerome, 40
Buber, Martin, 105
bulimia nervosa, 136–37
bullies, 78

case studies: Diana, 135–48

Justin, 23–25, 26–28, 29, 30, 32–36
Karen, 44–46, 49–53
Macy, 109–13
opioid addiction, 3–4
overview of, 7
Sally, 89–90, 97, 100. See also Jim case study
Centers for Disease Control and Prevention (CDC), 3
Centers for Medicare and Medicaid Services (CMS), 65, 124–25, 127
central sensitization, 43
CHADD, 98
“chasing the dragon,” 32
childhood trauma: addiction risk and, 17
psychopathology and, 41
chronic care model of addiction treatment, 153–54
chronic pain syndromes: disability claims for, 92
FDA and clinical trials of drugs for, 68–70
as growing problem, 42–43
new models for care of, 154–55
opioids for management of, 59–61
Clarke, L., 47
clinical trials of drugs, 68–70
CMS (Centers for Medicare and Medicaid Services), 65, 124–25, 127
cocaine, 140
communication between doctors, 126–28
compassionate doctors, 104–8
compulsion and addiction, 14
consequences of addiction, 14, 134–35, 142–45
contingency management, 88
control and addiction, 14
controlled prescription drugs: online pharmacies and, 28, 29
types of, 5–7
Controlled Substance Act (CSA), 5, 28
country mice and city mice, 77–78
cross-sensitization or cross-addiction, 21–22
culture: addiction and, 15–16
autobiographical narratives and, 40
cyberpharmacies, 27–30

Dannemiller Foundation, 59
DARE (Drug Abuse Resistance Education), 25n
Davis, Joseph, 97
DAWN (Drug Abuse Warning Network), 6
“deep web,” 30
defense mechanisms, 106–8
denial: of addiction, 85–86
as defense mechanism, 107–8
destigmatization of opioid therapy, campaign for, 58–64
Diagnostic and Statistical Manual of Mental Disorders (DSM), 14, 79
difference, as psychopathology, 43–49
direct-to-consumer advertising, 58n
disease model of addiction, 133–35
doctors: as baristas, 128–29
as compassionate, 104–8
as corrupt, 115–18
perks given to, by Big Pharma, 57–58
prescribing practices of, 56–57, 58n, 64
prisoners’ dilemma for, 86–88. See also overprescribing; psychiatrists
doctor shopping, 74, 77
Dole, Vincent, 82–83
dopamine, 80–81, 137
dose of opioids, 60
Drug Abuse Resistance Education (DARE), 25n
Drug Abuse Warning Network (DAWN), 6
Drug Addiction Treatment Act of 2000, 84
Drug Enforcement Agency, 103
drugs. See prescription drugs; and specific drugs
drug-seeking behavior: addiction and, 79–80
case study, 73–75
compassionate doctors and, 106–8
denial and, 85–86
malingering and, 79
methadone maintenance and, 83
prisoners’ dilemma for doctors and, 86–88
as pseudoaddiction, 61
strategies, 75–79
DSM (Diagnostic and Statistical Manual of Mental Disorders), 14, 79
Duggan, Mark, 91, 92, 101
Duhigg, Charles, 138
Dynamic Duos, 77
“dysphoria-driven” relapse, 81

eating disorders and addiction, 137

electronic medical records, 145
emotion dysregulation, 16–17
endorphins, 3n, 137
enriched enrollment study protocol, 68–70
epidemics: opioid, in U.S., 57n
prescription drug, 4–5, 25–27, 128. See also Big Medicine, role of, in
epidemic
exhibitionists, 76

Fassin, D., 97
Fauber, John, 68
FDA (Food and Drug Administration), 5–7, 67–71
Federation of State Medical Boards, role of, in epidemic, 64–65
fellowships in addiction medicine, 153
financial incentives and patient satisfaction, 124–25
Florida, pill mills in, 118
Foley, Kathleen, 60–61
Food and Drug Administration (FDA), 5–7, 67–71
42CFR Part 2, 126–28
Forman, R. F., 28
Freud, Sigmund, 41, 105, 106
Frueh, B. C., 100–101

Ganey, Rod, 123

gateway hypothesis of addiction, 22–23
Gawehn, Barbara, 154–55
genetic risk for addiction, 16–17
Good Samaritan laws, 150

Hacking, Ian, 41, 98

Haddox, David, 65
Harrison Narcotic Act of 1914, 31
heroin: addiction to, 30–33
complications of use of, 142–45
epidemics of, 57n
as illicit source of opioids, 109
recovery from, 33–35
types of, 140–41
“heroin chic” in Manhattan, 139
hijacked brain model of addiction, 79–82
Hoffmann, Felix, 31
homosexuality, as mental illness, 47
hospice care, 57
Hospital Consumer Assessment of Healthcare Providers and Systems
survey, 124–25
hospitals: electronic health records and, 145
eligibility service providers and, 94
42CFR Part 2 and, 127–28
incentive-based compensation for staff of, 122
 opioid addiction and, 2–3, 21, 39–40, 55–56, 110–11, 143
physician practices owned by, 119–20
quality measures of, 124–25
hydrocodone (Vicodin), 5–6, 24–25, 70–71

Iacono, W. G., 16–17

illness identity, 97–100
illness narratives: centralized pain syndromes, 41–43
difference is psychopathology, 43–49
drug-seeking behavior and, 85–86
overview of, 39–40
pain as dangerous, 40–41
shaping, 155
impersonators, 77
impulsivity, 16–17
incentive-based compensation, 122
industrialization of medical care, 118–26
Institute of Medicine committee, “Relieving Pain in America” report of, 63
insurance companies and addiction treatment, 131–32, 134
integrated health care systems, 119–20, 126
International Association for the Study of Pain, 63–64
Internet copycats, 78

James v. Hillhaven, 64
Jewish people and addiction, 23
Jim case study: AA experience, 12–14
career and leisure, 10–12, 13
drug-seeking behavior, 73–75, 89, 103–4, 115–17
early life, 9–10
follow-up after treatment, 149–50
opioid addiction, 21, 39–40, 55–56
opioid treatment, 131–32
Joint Commission on Accreditation of Healthcare Organizations (JCAHO or
The Joint Commission [TJC]), role of, in epidemic, 65–67
“junkie,” stigma of label of, 141

Kaiser Permanente Medical Group Santa Clara, 154–55

Kaizen Method, 118–19
Kentucky, class action suit filed by, 71
Kohut, Heinz, 105
Koob, George, 80
Kureishi, Hanif, 50

Lean, 29–30
Librium, 145–46
licensure of physicians and prescribing practices, 64
Lifetheuniverseandeverything.com, 29
Little Engines That Could, 78–79
losers, 76
low back pain, 22

malingering, 79
malpractice and untreated pain, 42
marijuana, 5
Medicaid, 94, 96
Medicaid Health Homes, 127
medical care: delivery of, 119–20, 126, 153–54, 156
industrialization of, 118–26
medicalization of poverty, 93–95
Medicare, 121
medication management, 121
Meier, Barry, 59
mental health care field, backward logic in, 46
Mental Health Parity and Addiction Equity Act of 2008, 134
mental illness: disability claims for, 92
drug and/or alcohol problems and, 2
Szasz on, 46–47
methadone maintenance, 33–34, 82–85
methamphetamine and Adderall, 45
Methoxetamine, 29
models of addiction: disease, 133–35
gateway hypothesis, 22–23
hijacked brain, 79–82
morphine milligram equivalents, 73
MRSA, 142
Myth of Mental Illness, The (Szasz), 46–47

naloxone, 150
narcissism, healthy, 104–5
narcissistic injury, rage, and retaliation, 108–9
Narcotics Anonymous (NA), 35
nature and addiction, 16–17
neighborhood and addiction, 17–18, 24, 138
neuroadaptation, 80–82
Norco, 73
nurse practitioners, 153
nurture and addiction, 17
Nyswander, Marie, 82–83

online pharmacies, 27–30

Opana, 71
“open-label phase” of drug trials, 69
opioid addiction: example of, 3–4
history of addiction and, 22
untreated, 143–44
opioid agonist therapy, 83–85
opioid epidemics in U.S., 57n
opioid induced hyperalgesia, 59
opioid refugees, 108–13
opioids: deaths from, 4
description of, 3n
heroin users and, 31–32
 overdoses from, 4–5
as schedule II drugs, 5–6
tramadol, 6–7
withdrawal from, 74, 111, 116–17. See also opioid addiction
overdoses: benzodiazepines and, 146
deaths from, 71, 151
heroin and, 31, 109
Medicaid and, 96
methadone prescriptions and, 84
naloxone for, 150
opioids and, 4–5
overprescribing: ending cycle of, 151–54
epidemic of, 4–5, 25–27, 128
of sedatives and stimulants, 150n
OxyContin, 57, 67, 71

pain: as dangerous, 40–41

as fifth vital sign, per TJC, 66
mental, as psychic scar, 41
untreated, and malpractice, 42. See also chronic pain syndromes
Pain Killer (Meier), 59
parents, 17, 27
Parsons, Talcott, 91
Passik, Steven, 109
passive aggression, 106–7
patient advocacy groups, 98
patient satisfaction surveys, 123–26
PDMP (Prescription Drug Monitoring Program), 103, 107–8, 150
peer influence, 17
Penandpaper.com, 35
Peters, Karen, 154–55
pharmaceutical industry. See Big Pharma
physician assistants, 153
physicians. See doctors; psychiatrists
physiologic dependence and withdrawal, 14–15
pill mills, 115–18
Pipemania.com, 29
placebo in clinical trials of drugs, 68–69
pleasure-pain balance, 80–82
Portenoy, Russell, 59–62, 63
post-traumatic stress disorder (PTSD), 41, 92, 93, 95, 96
poverty, medicalization of, 93–95
Power of Habit, The (Duhigg), 138
prescription drug epidemic, 4–5, 25–27, 128. See also Big Medicine, role
of, in epidemic
Prescription Drug Monitoring Program (PDMP), 103, 107–8, 150
prescription drugs: availability of, 17–18
controlled or scheduled, 5–7, 28, 29
for individual differences, 45–47
misuse of, 2–3, 18, 25–26, 48–49
spending for, 48
teens and, 23–25, 26–27, 36–37, 48–49. See also drug-seeking behavior;
overdoses; prescription drug epidemic; research; and specific drugs
Press, Irwin, 123
prisoners’ dilemma for doctors, 86–88
professional medical societies, role of, in epidemic, 62–64
professional patients: case study, 89–90, 146–47
description of, 90–91
illness identity and victim narrative of, 97–100
medicalization of poverty and, 93–95
risk for addiction in, 95–97
SSDI and, 90–93, 100–101
projection, 107
pseudoaddiction, 61
psychiatrists, 47–48, 121
psychological trauma, 41
PTSD (post-traumatic stress disorder), 41, 92, 93, 95, 96
Purdue Pharma, 57, 63, 64–65, 67, 71
Purple Drank, 29–30

quality measures, 124

Rapoport, Anatol, 87
Rechtman, R., 97
recovery from addiction, 18–19, 134
recovery movement, 99–100
refusal to treat addicted patients, 108–13
reinstatement, 21–22
relapse, 21–22, 81
Relative Value Units, 121
“Relieving Pain in America” (Institute of Medicine committee report), 63
research: of academic physicians, 58–62
clinical trials of drugs, 68–70
“research chemicals,” 29
reward circuity of brain, 15, 22, 137
rewards, alternative, as reducing substance use, 138
risk for addiction, 16–18, 24, 95–97, 138
role-playing tabletop games, 35–36
Rush, Benjamin, 133

schedule I drugs, 5, 31
schedule II drugs, 5–6, 45, 70
schedule III drugs, 6
schedule IV drugs, 6
schedule V drugs, 6
school-based prevention programs, 25n
sedatives: overprescribing of, 150n
prescriptions of, 4
as schedule IV drugs, 6
Senators, 76
side effects of opioids and dose, 60
Silk Road website, 30
social networks, AA as changing, 19
social roles, 91, 98
Social Security Disability Income (SSDI): increases in claims for, 91–93
professional patients and, 90–91, 100–101
spiritual growth, pain as opportunity for, 40
splitting, 107
SSI (Supplemental Security Income), 92
Stages of Change Model, 81–82
Sternbach, Leo, 145
stigmatizing language, xi
stimulants: for ADD, 45–46
for adolescents, 48
effects of, 50
overprescribing of, 150n
prescriptions of, 4
as schedule II drugs, 6. See also Adderall
Suboxone treatment, 34–35, 84–85, 132
substance, definition of, 1n
substance use, alternative rewards as reducing, 138
substance use disorder: access to information about, 126–28
definition of, 1n
mental illness and, 2
screening and treatment of, 133–34. See also addiction
Sunshine Act of 2014, 58
Supplemental Security Income (SSI), 92
sycophants, 76
Szasz, Thomas, 46–47

tabletop games, 35–36

Taub, Shais, 23
teens and prescription drugs, 23–25, 26–27, 36–37, 48–49
terminology, xi, 14n
therapeutic community, importance of, 155
thought leaders, 58–59
Tit for Tat strategy, 87
TJC. See Joint Commission on Accreditation of Healthcare Organizations
tolerance, 15, 60
training in addiction medicine, 152–53
tramadol, 6–7
twelve-step self-help community, xi. See also AA
twins, 77

Ulbricht, Ross W., 30

Vaillant, George, 106

Valium, 146
Veterans Disability Compensation (VDC), 92, 96
Vicodin (hydrocodone), 5–6, 24–25, 70–71
victim narrative, 97–100
Visual Analog Scale of pain assessment, 66
Volkow, Nora, 79–80

Walsh, C., 29
warning system, pain as, 40
weekenders, 76–77
Wen, Patricia, 95
Wise, Roy, 18
withdrawal: from alcohol, 127–28
from opioids, 74, 111, 116–17
physiologic dependence and, 14–15
symptoms of, 81
Wood, Alexander, 42
Wright, C. R. A., 30–31

Zohydro, 70–71