Wisdom Comes by Disillusionment

Reflections on Dopesick

My patient (no, not you) comes in for his Adderall refill. He has been stable on his current dose for years, without escalation or any significant side effects. He is happy with the medication - better focus, less distraction - and credits it for making him productive in a demanding job at a fintech startup. 

He is only a little younger than me, meaning that when my patient was growing up, practically no one was on stimulant medications. And still, even without Adderall, he did well enough in school to get into an Ivy League college (I know, I know, none of us would be admitted anywhere nowadays, but still…), excel at a competitive grad school, and succeed in his field - all of which would seem to demand a pretty highly developed ability to focus and concentrate.

And yet now, he - like so many of my patients his age and younger - are prescribed a daily pill without which his ability to succeed at work would presumably suffer. Not that ADD didn’t exist back then, mind you, but somehow the pool of patients being treated for it has expanded by an order of magnitude. How? Why?

Is it being overdiagnosed? Was it being underdiagnosed? Used now for milder cases? Misused as a competitive advantage? And how much does it really matter, anyway? After all, these medications are 1. FDA approved, 2. indicated for a real diagnosis, and 3. pretty helpful, including for my own son (and his friends…and their friends!).

And yet…

Rachel and I are watching the Hulu series, Dopesick, recommended to us by her psychiatrist sister. It’s a drama about the opioid crisis and how it was created by Purdue Pharma and the Sackler family in their campaign to make Oxycontin into a billion-dollar blockbuster drug. 

A central thesis of the show (so good btw- highly recommend!) is that Purdue financed and essentially created - as a marketing ploy - the whole idea that doctors systematically undertreat pain. 

They invented “Pain”-  not the physiological phenomenon, obviously, but the whole movement that came to surround it in the late 90’s: the ubiquitous pain scale, with its smiley and frowny faces from one to ten; the slogan that “pain is the fifth vital sign”; the idea of rating hospitals and doctors based on their treatment of pain; the notion that undertreating even mild pain is a gross betrayal of the Hippocratic oath. All of it conceived and underwritten to sell Oxycontin.

Wait, what?? 

Rachel and I looked at each other with surprise-emoji faces. We were residents and young attendings during the late nineties and early aughts, exactly at this time. Treating the patient’s pain was drummed into us constantly. And not just by the drug reps - from whom we were happy to take free pizza and subs, all the while feeling blithely confident that we were immune to their salesmanship - but by our senior residents, our attendings, and the textbooks and journal articles we relied upon for truth.

After all, what is truth in medicine? How do we know what we know to the point that we feel confident doing what we do? The answer is supposed to be a combination of evidence and expert opinion. Medical training is still to a large extent an apprenticeship, with knowledge passed down from attending to resident to medical student, ideally grounded in evidence derived from rigorous clinical trials.

Call it pathetically naive, but it never really occurred to us at the time - at least not to me - that the higher sources we relied upon for truth could be just as corruptible as the poor fools whose prescribing habits were influenced by pizza, pads, and pens. The drug reps, lord help us, were nothing but decoys!

Anyway, I did some reading, just to see if the show overstated the case. Newsflash: it did not.

I also came across some interesting facts. It turns out that way before Oxycontin was a gleam in the Sacklers’ eye, Purdue made a fortune on another drug: Valium. Remember Valium? Mother’s little helper from the 1950’s?

And while the litigation around Oxycontin has undoubtedly thrown a wrench into the works, Purdue still has new drugs in the pipeline. In fact, it recently launched one called Adhansin XR. Never heard of it, so I looked that up too. It’s a controlled release stimulant, indicated for the treatment of ADHD.