Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked and Why It's So Hard to Stop ========================================================================================= * Matthew Weinlander * Debra A. Pinals By Anna Lembke, MD. Baltimore: Johns Hopkins University Press. 2016. 172 pp. $19.99 *Drug Dealer, MD* is a comprehensive and systematic look into several factors that contribute to the current opioid epidemic. This book is divided into 10 chapters. The first two chapters offer a common definition of addiction, which is familiar to mental health professionals, and a narrative describing the advent of prescription analgesics as a gateway to addiction. Chapter three discusses the physical and psychological components of pain in the context of both acute and chronic pain syndromes. The next two chapters are focused on the effect of direct-to-consumer marketing on the promotion of medication consumption and then addiction as the driver of malingering. Chapters six and seven discuss the changing roles of “patient” and “physician” in society. The book then describes a view of the commoditization of medicine and the role insurance companies play in discouraging treatment of addiction. The final chapter is one in which Lembke calls for change in the “cycle of compulsive prescribing” (p 149). In chapter eight, Lembke tries to explain how we ended up in an opioid crisis. She lays considerable weight on the patient–physician relationship being crippled and co-opted by the intervention of the Centers for Medicare and Medicaid Services, state medical boards, hospital legal counsel, patients' legal counsel, patient relations, billing, disability claims, The Joint Commission, private insurance, and Big Pharma, resulting in medicine being treated as a profit-driven industry to the detriment of patient care. In the closing chapters, the author laments the lack of systemic investment (i.e., monetary and educational) in treatment of addiction, and calls for deep change within the segregated, managed-care system of health care delivery. Dr. Lembke is the Chief of Addiction Medicine and Assistant Professor at Stanford University School of Medicine. In this text she draws on her 20 years of clinical experience, related in vignettes throughout the book, as well as interviews with colleagues, pharmacists, social workers, nurses, hospital administrators, insurance executives, journalists, economists, advocates, and patients and their families. Lembke cites staggering statistics that illustrate the rise of the opioid epidemic. She describes how the Centers for Disease Control and Prevention declared a prescription drug epidemic after deaths from opioid pain medications quadrupled between 1999 and 2013. She also notes that pharmacy sales of opioid analgesics quadrupled from 1999 to 2011. In 2010, deaths resulting from opioid overdose exceeded those from motor vehicle collisions for the first time ever in the United States (pp 4–5). Lembke describes that, although 40 million people in the Unites States are affected by addiction (more than cardiovascular disease at 27 million people and diabetes at 26 million), there have been staggeringly few health care dollars allocated to addiction treatment (1% of the U.S. health care budget). She notes that insurance companies do not reimburse for addiction treatment on par with reimbursement for other medical illnesses (p 133). The author argues that an integral component to the current crisis is the evolution of social roles, which emerge within a given society due to a combination of social norms, the social contract, and economic incentives. Further, she asserts that social roles come with a collection of obligations and responsibilities. As little as 60 years ago, the social role of the patient was “to get well,” and the role of the physician was “to minimize illness and disability” (p 91). She states that the rise of disability and a culture of victimhood contributed to the creation of the professional patient role and a corresponding role for physicians in which, with little time and few external resources, they maintain illness, especially in the context of addiction, where the patient seeks ongoing prescriptions. In this book, Lembke argues that the professional patient rose out of these social trends. She comments on the rising number of adults receiving some form of income through public disability or other public assistance. She puts forth that the reason for these large increases in recipients of disability income are in part due to the perception of disability programs as “non-employability insurance programs” (p 92). Of course, not all people on disability use these programs in that way, and many are truly disabled. Lembke provides data suggesting that as the monetary value of Social Security disability insurance rose in the 1980s and the disability screening laws changed to reflect subjective experience of pain and distress, the numbers of patients on disability increased dramatically. She opines that many claims for disability center around illnesses that have more subjective symptoms (e.g., depression, post-traumatic stress disorder, fibromyalgia, chronic pain, multiple sclerosis, chronic fatigue syndrome, and chronic temporomandibular disorder). With the advent of managed care, an emphasis on patient satisfaction scores, productivity goals, and the establishment and pursuit of the ideal of efficiency of care delivery, it becomes increasingly difficult for individual practitioners to extricate themselves from the new role of the person who keeps the patient sick. In some cases, the patient–doctor interaction is reduced to a business arrangement, one in which helping the patient secure disability income becomes a primary goal. Physicians are at the same time pressured to maximize productivity targets, and in doing so justify the costs of administration and oversight. She depicts how this quickly devolves into industrialized health care delivery and dehumanization of those involved (both patient and physician). Having established the idea that there are many societal, psychological, and biological factors underlying the opioid epidemic, Lembke calls for change. In its focus on unpacking the complex dynamics involved in the generation of the crisis, the book succeeds, in part. The book is obviously, by its title and content, in large part focused on the prescribing physician as one root of the opioid crisis. Where the book falls short is in the cynicism in the vignettes and some tinge of lightness and sarcasm in the writing. It is a brief book and it covers a lot of ground, but it seems to lack full attention to myriad factors beyond the central focus on the patient–physician relationship that have also significantly contributed to the whole epidemic. Not all doctors are as robotic as depicted in some of the vignettes. Some work hard to get their patients into the right and necessary proper care. The author suggests that integral steps to combating the crisis include awareness of the issues, expanding education on addiction, and delivering care in a chronic-care model with expanded time for the patient–physician relationship. Though all the discourse does a good job in raising awareness, the reader is left wondering if there are any practical suggestions for individual action within the current system. With all these complex issues, Lembke does not provide for the reader a pragmatic discussion of next steps, short of revolution. The target audience of this book seems to be the public at large. It is written in an easily readable style with “stories” of patients and doctors. It is not written as a textbook. For forensic psychiatrists, it does not give more detail about the interplay between psychiatry and the law or the legal regulation of clinical practice in a manner that connects to landmark legal decisions or to current debates. A welcome addition for forensic psychiatrists might have been a discussion of the ethics principles at play, which would be of great interest to many in the field. Although this book does not deal directly with forensic psychiatric issues, it seems well written for its intended audience—the lay public. As such, even forensic professionals might find it an interesting read for basic background on a complex subject. ## Footnotes * Disclosures of financial or other potential conflicts of interest: None. * © 2019 American Academy of Psychiatry and the Law