Tuesday, December 28, 2021

Dopesick, Doctors, and Addicts

 by Sherry F. Colb

I recently watched and very much enjoyed the television mini-series Dopesick. It offers a (barely) fictionalized account of the unbridled greed of Purdue Pharma and the Sackler family. The story was recently in the news again when a federal judge overturned a bankruptcy settlement that had mostly shielded the Sacklers' personal assets from lawsuits against the company and its shareholders. The Sacklers themselves, the greedy people who marketed poison to the masses in order to get richer, may therefore have to pay out of their own pockets for some of the damage that they did. 

The story involves a drug called Oxycontin, an opioid that Purdue Pharma (i.e., the Sacklers) claimed was not addictive. The company sent out drug representatives to market Oxycontin ("Oxy") directly to doctors. In the show, a kind and decent doctor played by Michael Keaton prescribes the drug because he believes what the rep has told him: the Oxycodone in Oxy is coated and therefore enters the person's system gradually and does not cause addiction. The falsity of this claim becomes increasingly clear as crime skyrockets in Appalachia, where chronic pain is endemic. As patients become addicted to the drug, they simply must have it, even if that means robbing a pharmacy or their parents' jewelry box.

The show is great. It is fast-paced and interesting and has relatable characters as well as villains one loves to hate. One thing I especially liked about the show is that it begins to shatter the myth that only weak-willed losers behave in anti-social ways when they become addicted to drugs. The county doctor, an ethical and kind person, begins stealing Oxy from his patients and otherwise crossing ethical lines. The word "dopesick," which I had not heard before, refers to the feeling one has when suffering intense withdrawal, the sensation that one will die if one cannot get the drug in short order. Even a person who has never experienced addiction can imagine being sick and feeling like he will die if he cannot have a particular medicine. Under those conditions, a person would likely do anything he could to get the drug.

The message that we should not judge people who are addicted to drugs is a very important one that plainly has not penetrated our society thus far. I listened to an old episode of The Daily Show in which Justice Sotomayor was Trevor Noah's guest. Justice Sotomayor is one of the only decent human beings left on the Supreme Court, so I only reluctantly tell this story, not to single her out but to show how pervasive the attitude she manifests is. Justice Sotomayor told Trevor about going into a restroom when she was about thirty and injecting insulin. Two other women entered the restroom during the process, and one whispered to the other "that's an addict." Justice Sotomayor explained to the whisperer that she (Justice Sotomayor) was not an addict, that she is just a diabetic taking insulin and that the woman should not assume the worst but should instead ask questions.

My first thought was "why is 'addict' the worst?" A person who needs insulin is quite similar to a person addicted to an opioid. Both people will suffer pain, distress, and danger if they do not get the medicine they need. The only difference that might bear on "fault" is the fact that the person shooting up heroin might have "chosen" to take heroin in the first place. But we know that heroin addicts are sometimes people prescribed opiates who then become addicted to the opiates and need to turn to a cheaper source if they are uninsured. They are not at fault. And even people who try heroin do not expect to become addicted.  Most people, by the time they look like "addicts," are no longer seeking the high that the drug might have originally provided. They are instead trying to make their intense suffering stop. Both the diabetic and the addict are doing what they can to avoid or to stop feeling awful. The symptoms of withdrawal can be so extreme that it can be dangerous for a patient to go "cold turkey" even if he has the "strong will" that people who judge addicts believe that they, the judges, would have.

I think that if Trevor had made this point (he did not), Justice Sotomayor might have agreed. She was reflecting a societal prejudice without really giving it a lot of thought. I suspect that she would be empathic toward an addict. It would surprise me if during her years as an attorney and a judge, she did not encounter "addicts" for whom she felt sympathy. That her first impulse was to treat as a grave insult the conclusion that she was addicted to a substance is unfortunate, however, and tells us how much work we still have to do.

Back to Dopesick, though, one feature of the otherwise excellent miniseries bothered me. The series directed all blame for the Oxycontin opioid crisis on the Sacklers and the Purdue Pharma reps. Let me say, first, that I believe the Sacklers are extremely culpable in connection with the harm that Oxycontin did to individual lives, to families, and to communities. Nothing I say here should be understood to take them off the hook for their misconduct. If a prosecutor were inclined to bring murder charges against the Sacklers, I would not condemn that decision. The Sacklers are evil.

But what about the doctors? We tend to accept without question the standard story that doctors are not pharmacists, that they therefore know very little about drugs other than what pharmaceutical representatives tell them. As it turns out, however, when pharmaceutical representatives fly doctors to beautiful locales, the doctors end up prescribing the drugs hawked by those pharmaceutical representatives. It is only human to do so, but doctors often believe themselves to be super-human or think--erroneously--that as long as they are aware of what the pharmaceutical representatives are up to, the doctors will not end up favoring that representative's drug over other, perhaps better, alternatives. Doctors have an obligation to be aware of what any lay person to look it up knows: accepting gifts from reps will distort a doctor's behavior.

More importantly, doctors should know something about the drugs they prescribe. I remember talking to a doctor friend once who confided in me that he really knew nothing about the drugs other than X treats Y and A treats B. He seemed about as curious regarding the chemicals he was inflicting on his patients as he might be about the correct amount of Chlorine to put in a swimming pool he never frequents. Doctors learn all sorts of things in or to qualify to go to medical school that have little to do with the practice of medicine. I imagine that organic chemistry, for example, comes up far less frequently than pharmacology in a typical medical office. 

The goodness and kindness of the Michael Keaton doctor character seem to exonerate the doctors who prescribed Oxycontin to their patients. How could they have known? Well, we give licensed doctors a great deal of power and a greater share of money than many of their patients have in return for doctors performing a service for the people. I find it remarkable that drug dealers on the street managed to figure out that a person could get high from Oxycontin simply by licking off the magic "coating" on the outside and then crushing the remainder and snorting it, but doctors lacked the imagination to draw the same conclusion.

I tend to think that doctors fail to do a lot of follow-up to find out whether their prescribed course of conduct was helpful, useless, or affirmatively harmful. When my mother was aging and suffered from dementia, her doctor proposed a surgery that would result in her needing a colostomy bag. When asked whether the surgery might make it difficult for her to live in an old age home, the doctor said he had never heard of any such problem. What I did not realize at the time was that he almost certainly had not heard of the problem because he did not follow up with patients, my mother included. It turned out that the surgery did make her stay at the old age home far worse than it otherwise would have been. I regard what the doctor said to me as no better than a lie.

Why no better than a lie? The doctor failed in his obligations at two separate points. First, he had been recommending ostomy surgery in the past and did not investigate after the fact whether the surgery helped, did nothing, or harmed the patient. He got his money, so why would he bother doing such followup? If the patient had made another appointment to tell him what had worked, what hadn't, and what had made life a living hell, he would have probably seen the patient. But it is really his obligation, not the patient's, to be aware of whether his actions are helping, harming, or doing nothing. No one should have to pay him for a visit at which he learns that the proposed surgery was a disaster. But that is the only way he would have found out about my mother's experience or that of any other patient for whom he had prescribed ostomy surgery.

The second bit of malfeasance by the doctor was the statement that he had not heard any such complaints. That statement strongly implies that if a patient had had a terrible experience with the surgery at issue, then the doctor would have heard about it. But of course, he would not have because he did nothing to find out how the surgery had worked out for the various patients. So long as the surgical wounds healed (there's a visit for that), he was done with the patient. So he effectively pretended that he was doing what he was supposed to be doing, thus giving rise to a false confidence among the patient's family members that life would not become unfathomably worse because of the surgery (which it did). My mother died a year to the day after the surgery.

The doctors who prescribed Oxycontin were and are the gatekeepers for pharmaceuticals. I know that pharmacists know much more about drugs than doctors do, but pharmacists may not prescribe. As the gatekeeper, a doctor has an obligation to know and keep track of what the drugs she prescribes are doing to patients. Had doctors been awake at the switch, they might have noticed that Oxycontin was, magic claims to the contrary notwithstanding, as addicting as any other opiate. And they might have stopped prescribing Oxycontin before addiction rose and crashed all over the country like a toxic tidal wave.

Doctors were not primarily victims of the Sacklers (as Michael Keaton's character was in Dopesick). They were accomplices. And more significantly for future assessments of guilt, they are accomplices in the treatment decisions they make that go wrong. It is the doctor's responsibility to gather enough information (including facts about a patient's living situation as well as the impact of prior recommendations on prior patients) to make a wise decision. The opioid crisis just gives us one more reason to hold doctors accountable for signing a pad and washing their hands of the results. It is high time that doctors make inquiries that would properly inform a claim that "no one has complained." Some doctors already do, but those that do not should be put on notice. They will not always be able to say "How could I know? The drug rep. giving me free merch or flying me to a conference in Tahiti said my patients would be fine." Dopesick could have used another villain.