Drug Dealer, MD

1. Doctors, Not Dealers, Fuel the Prescription Drug Crisis

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.

Prescription origins. The prescription drug epidemic is primarily driven by the overprescribing of addictive medications by doctors, not by illegal street drug sales. Most people misusing or addicted to prescription drugs obtain them directly or indirectly from a doctor's prescription, highlighting the medical system's role in the crisis.

• Only 4% of those misusing prescription drugs get them from a drug dealer or stranger.
• In 2012, enough opioid prescriptions were written to medicate every American adult for a month.
• This overprescribing has led to a dramatic increase in addiction and overdose deaths.

Gateway to addiction. Prescription drugs, especially opioids, have become a new gateway to addiction, particularly for young people. What was once a progression from legal drugs to illegal drugs has been reversed, with prescription drugs often being the first exposure to addictive substances.

• Teens are especially vulnerable due to their developing brains and social pressures.
• Easy access to prescription pills blurs the lines between "soft" and "hard" drugs.
• Online pharmacies further exacerbate the problem by providing easy access to controlled substances without prescriptions.

The shift in the gateway. The traditional gateway hypothesis, where legal drugs lead to harder drugs, has been inverted. Prescription drugs are now often the first step toward addiction, highlighting the need for stricter prescribing practices and better education about the risks.

2. Pain Narratives and the Medicalization of Difference Drive Overprescribing

Today, pain is considered an almost intolerable sensation for patients to endure.

Pain as an enemy. Modern culture views pain, both physical and mental, as something to be avoided at all costs, leading to a lower threshold for pain tolerance and increased demand for pain relief. This view is fueled by the belief that pain can cause permanent neurological damage, creating a sense of urgency to treat it immediately and completely.

• The concept of chronic pain as a condition independent of illness or injury is a relatively recent phenomenon.
• Mental pain is also viewed as a "psychic scar" that needs to be treated, often with medication.
• This has led to an overreliance on prescription drugs to manage all forms of discomfort.

Medicalizing difference. Individual differences in emotionality, cognition, and temperament are increasingly defined as illnesses, requiring medical treatment to normalize them. This trend has led to the overdiagnosis and overmedication of conditions like ADHD, anxiety, and insomnia.

• Human differences are framed as brain pathology, leading to the use of psychoactive drugs to manage them.
• This approach ignores alternative narratives that celebrate human diversity and consider sociological, existential, and spiritual etiologies.
• The result is a generation of young people who have embraced the idea of "better living through chemistry."

The unintended consequences. The medicalization of difference and the cultural aversion to pain have created a perfect storm for the prescription drug epidemic. The easy availability of pills, combined with the belief that they are the solution to all forms of discomfort, has led to widespread misuse and addiction.

3. Big Pharma and Big Medicine: A Dangerous Alliance

Big Medicine was the engine behind the opioid paradigm shift, and Big Pharma the stealthy and powerful caboose.

The pro-opioid movement. In the 1980s, a pro-opioid movement, fueled by pharmaceutical companies and academic physicians, encouraged doctors to prescribe opioids more liberally for chronic pain. This movement was based on flawed research and misrepresented data, leading to a dramatic increase in opioid prescriptions.

• "Thought leaders" were paid by Big Pharma to promote liberal opioid prescribing.
• Misconceptions about the effectiveness of opioids for chronic pain and the low risk of addiction were widely disseminated.
• The concept of "pseudoaddiction" was used to justify increasing opioid doses in patients exhibiting drug-seeking behavior.

The role of medical societies. Professional medical societies, often funded by the pharmaceutical industry, also played a role in promoting opioid prescribing. They issued guidelines urging doctors to prescribe more opioids for pain and stigmatized doctors who were reluctant to do so.

• The American Pain Society and other organizations declared that there was insufficient evidence to conclude that opioids, when prescribed for pain, can result in addiction.
• The Joint Commission made "pain" the fifth vital sign, further emphasizing the need to treat pain aggressively.
• The FDA approved new opioids using flawed study protocols, making it easier for pharmaceutical companies to get their drugs on the market.

A tangled web. The prescription drug epidemic is the result of a complex interplay between Big Pharma, academic physicians, professional medical societies, regulatory agencies, and the FDA. These groups, driven by a combination of financial incentives and misguided beliefs, created a system that encouraged overprescribing and contributed to the current crisis.

4. The Hijacked Brain: Addiction vs. Malingering

According to neuroscientists, addiction is a disorder of the brain’s reward circuitry.

The three C's of addiction. Addiction is characterized by the three "C's": loss of control, compulsion to use, and negative consequences. These criteria highlight the behavioral aspects of addiction, but the underlying cause is a change in the brain's reward system.

• Physiologic dependence and withdrawal are associated with addiction, but not necessary for diagnosis.
• The brain's reward circuitry is hijacked by addictive drugs, leading to intense cravings and compulsive drug-seeking behavior.
• Over time, the brain adapts to the drug, requiring more and more to achieve the same effect (tolerance).

Malingering vs. addiction. While some drug-seeking patients may be malingering (feigning illness for personal gain), many are genuinely struggling with addiction. The "hijacked brain" model of addiction suggests that the drive to obtain and use drugs becomes a primary motivation, overriding other needs and desires.

• Malingering is defined as feigning illness with the conscious intent of obtaining some tangible good not related to illness recovery.
• Drug-seeking behavior is often a result of the altered brain state caused by addiction, not simply a conscious choice.
• The neurobiological changes associated with addiction can make it difficult for individuals to stop using drugs, even when they want to.

The need for compassion. Understanding the neurobiological basis of addiction is crucial for developing effective treatment strategies and reducing the stigma associated with the disease. It also highlights the need for compassion and empathy when dealing with drug-seeking patients.

5. Professional Patients: Illness as Identity and a Right to Be Compensated

Today staying sick has become a means of survival and keeping patients sick a new way of helping.

The rise of professional patients. A growing number of patients are adopting the "sick role" as a means of survival, often relying on disability payments and prescription drugs to manage their lives. These "professional patients" are not necessarily malingering, but rather have internalized an identity as a person with an illness.

• The number of adults receiving disability payments has increased dramatically in recent decades.
• Mental illness and chronic pain disorders are the leading causes of disability claims.
• Poverty and lack of education are strong predictors of who seeks disability, independent of illness status.

The medicalization of poverty. Doctors and health care institutions are complicit in the medicalization of poverty, often helping patients secure disability payments as a way to reduce the number of uninsured patients they have to treat. This creates a system where staying sick becomes a means of financial survival.

• For-profit firms help hospitals enroll patients in disability programs.
• Doctors are incentivized to fill out disability forms in exchange for cash.
• The result is a system that perpetuates illness and discourages recovery.

The victim narrative. Professional patients often adopt a victim narrative, seeing themselves as perpetually victimized by forces beyond their control. This narrative can make it difficult for them to accept responsibility for their own health and to engage in treatment. The adoption of illness identities is also driven by the breakdown of traditional social roles, with illness providing a way to define the self in a rapidly changing world.

6. The Compassionate Doctor's Dilemma: Narcissistic Injury and Primitive Defenses

Doctors are by and large pleasers.

The compassionate doctor. Doctors are often driven by a desire to help others and are invested in being successful healers. They are trained to empathize with patients and to believe their stories, creating a foundation of trust and mutual cooperation.

• Doctors are often pleasers, seeking to meet the needs of their patients.
• They are narcissistically invested in being successful doctors, measuring success by positive patient interactions and expressions of gratitude.
• The doctor-patient relationship is often seen as a sacred bond, based on trust and mutual respect.

The narcissistic injury. When a doctor encounters a drug-seeking patient, they often experience anxiety and a narcissistic injury, a blow to their sense of competence and self-esteem. This can lead to a range of primitive defense mechanisms, including passive aggression, projection, splitting, and denial.

• Doctors may project their own feelings of inadequacy onto their patients, seeing them as morally deficient.
• They may engage in splitting, categorizing patients as either "good" or "bad."
• Denial is a common defense mechanism, leading doctors to ignore suspicious patterns of medication use.

Narcissistic rage and retaliation. When these defenses fail, doctors may react with narcissistic rage and retaliation, refusing to treat patients they perceive as manipulative or dishonest. This can lead to patients being labeled as "opioid refugees," further exacerbating the problem. The idealized response, by contrast, is compassion and professionalism even in the face of these challenges.

7. Pill Mills and the Industrialization of Medicine

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.”

Pill mills and corrupt doctors. Some doctors, driven by greed, have turned to prescribing addictive medications as a way to make money, creating "pill mills" where patients can easily obtain prescriptions for cash. These doctors represent a small but significant part of the problem.

• Florida became an epicenter for pill mills, with a large number of pain clinics dispensing opioids for profit.
• Law enforcement crackdowns have reduced the number of pill mills, but the problem persists.
• These doctors have abdicated their ethical and professional responsibilities to their patients.

The Toyota-ization of medicine. The increasing industrialization of medicine has transformed the doctor-patient relationship, with a focus on efficiency, productivity, and profit. Doctors are now expected to "meet requirements" and "increase productivity," often at the expense of patient care.

• Doctors are increasingly employed by large health care systems, reducing their autonomy.
• Treatment options are often dictated by hospital administrators, insurance companies, and regulatory agencies.
• The focus on billing and patient satisfaction surveys can incentivize doctors to prescribe more medications and spend less time with patients.

The impact on care. The industrialization of medicine has created a system that prioritizes quantity over quality, leading to a decline in the doctor-patient relationship and an increase in overprescribing. Doctors are often forced to make decisions based on financial incentives rather than the best interests of their patients.

8. Addiction: The Disease Insurance Companies Still Won't Pay to Treat

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.

The history of addiction as a disease. Despite the scientific evidence supporting the disease model of addiction, insurance companies continue to discriminate against patients seeking treatment for substance use disorders. This discrimination is rooted in a long history of viewing addiction as a moral failing rather than a medical condition.

• Dr. Benjamin Rush argued that chronic drunkenness is a biological disease as early as 1819.
• The first "sober houses" were created in the mid-1800s, but addiction treatment has remained marginalized.
• Despite the passage of the Mental Health Parity and Addiction Equity Act, insurance companies continue to find loopholes to deny coverage for addiction treatment.

The cost of inaction. The failure to treat addiction as a disease has led to a massive public health crisis, with millions of people suffering from untreated substance use disorders. The medical consequences of addiction are costly, and the lack of access to treatment only exacerbates the problem.

• Only 1% of the total health care budget goes to treating addiction, despite its high prevalence and cost.
• Doctors are poorly trained in the treatment of addiction, and many turn away patients with substance use disorders.
• The lack of access to treatment perpetuates the cycle of addiction and its associated medical complications.

The need for parity. Addiction treatment must be integrated into the mainstream health care system and reimbursed on par with other medical illnesses. This requires a fundamental shift in how we view addiction and a commitment to providing evidence-based treatment to all who need it.

9. Stopping the Cycle: A Call for Systemic Change

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 need for a new approach. The prescription drug epidemic is a complex problem that requires a multifaceted approach. We must address the underlying cultural, economic, and systemic factors that contribute to overprescribing and addiction.

• Cultural narratives that promote pills as quick fixes for pain must be challenged.
• The influence of Big Pharma and Big Medicine on prescribing practices must be curtailed.
• The medicalization of poverty and the financial incentives for staying sick must be addressed.

Systemic changes. We must restructure the health care system to prioritize patient well-being over profit and to provide doctors with the tools, time, and resources they need to treat complex biopsychosocial problems.

• Addiction treatment must be integrated into all levels of medical education.
• Doctors must be reimbursed for talking to and educating their patients, not just for prescribing medications.
• The doctor-patient relationship must be prioritized as the foundation of good care.

A call to action. The prescription drug epidemic is a call to action for all of us—doctors, patients, and policymakers. We must work together to create a health care system that is truly focused on healing and that provides access to evidence-based treatment for all who need it. The time for change is now.

Last updated: January 14, 2025