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Inside the Anger

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Last week, I wrote about how 12-step programs that hire exclusively from the small pool of “12-step successes” may be misleading their patients — and how patients are taken in by their own tendency to trust in anecdotes more than statistics and data. This week I want to write about a very similar trend among those who defend 12-step treatment programs against the advance of other, more scientific methods of treatment.

I spend a great deal of time on various forums online, debating the merits of different forms of addiction treatment with professionals and laypeople alike. I see it as a vital and valuable way to stay informed and relevant to the conversations going on in the community I am trying to serve. One thing I’ve noticed over the course of these discussions is that people who tend to support 12-step programs tend to be much more emotionally invested in their arguments, and often react to disagreement as though it were a personal attack.

I don’t think this has anything to do with these people in particular; I’ve gotten enraged, nearly hysterical responses from people who work at these places, people who don’t, even people who relapsed after undergoing a 12-step treatment. I think a feeling of deep emotional attachment to the ideals of 12-step programs are a symptom of the way these practices are run. I mentioned last week that anecdotes, especially when they are highly emotionally charged and are coming from people in positions of authority, may well be the most powerful persuasive force that can act on a human mind. 12-step programs engineer situations that harness this force in their favor. They present sick, frightened, desperate patients with calm and reassuring counselors (remember, all drawn from a small percentage of addicts), and have those authority figures relate stories of how their lives were ruined and 12-step programs saved them.

The effect this has is very difficult to overstate. It is, as I said, very persuasive — but it’s persuasive on an emotional basis rather than an intellectual one. Emotional certainty can be very useful and necessary in our lives, but it can also cloud our judgement and make us miserable when we are confronted with facts that disprove the foundations of our emotional knowledge.

This is what I believe is going on today in the ongoing war between 12-step supporters and medical professionals who advocate maintenance therapy for addiction. 12-step programs have become almost a kind of religion; they introduce their patients to an entire moral worldview, one based on willpower and a “Higher Power”, complete with narratives of sin and redemption. They introduce this system in very stressful and vulnerable situations, and encourage their patients to rebuild their lives on this foundation. There would be nothing wrong with this, if the foundation itself wasn’t fundamentally, factually flawed. It turns out that addiction is not solely a moral failing, and often cannot be overcome by willpower alone, the same way that willpower can’t overcome diabetes. But statistics and science that try to make that point are rejected and even attacked, because they threaten the deep emotional foundation on which 12-step patients have constructed their world. Because it’s an emotional threat, the reaction is emotional as well; I, as a physician, don’t have a particular emotional attachment to any one mode of treatment, and I’m willing to debate them all on intellectual grounds. That’s why I’m often caught off-guard by the intensity of the anger that I find when talking to those who have been through this 12-step persuasive process.

I want to say again that I don’t think these people are “stupid”, or weak, or that they have some kind of innate problem. I believe they have been taken advantage of by a system that, wittingly or not, has been fine-tuned over decades to make its patients believe that no other method or provider can be trusted.

It is my hope that, through education and continual refinement of the science behind addiction treatment, we can replace this manipulative system with one based in factual reality, which will hopefully help more patients to live healthier lives.

12-Step Statistics

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It’s common for addiction treatment centers and 28-day rehabs to advertise that their staff is made up only of ex-addicts. They treat it as a selling point that patients won’t talk to anyone who hasn’t found success fighting addiction — if not at that particular center, then almost certainly through similar methods of abstinence, willpower, roleplaying, and lectures.

There’s a valuable element of encouragement for patients to see and talk to role models who have overcome the problems they’re facing. It is completely natural and commendable for people who have struggled with addiction to want to help others who are currently struggling. But by hiring only one subset of people, these treatments end up spreading a deeply misleading and harmful idea of addiction, which can delay or even stop their patients who are on their own “roads to recovery”.

First of all, hiring only those who have “succeeded” on 12-step programs is playing a statistics game. Out of all comers — anyone who considers themselves an addict or alcoholic and attends at least one 12-step meeting — between 90 and 95% find the 12 step program doesn’t work, and leave. Success rates given by 12-step treatment centers are often framed with the understanding that these 90% of people don’t count — the 12 step has an “80% success rate”, which means “successes” are 80% of those who were in the 10% who stayed. While this might be a good argument that the 12-step treatment works well for a certain kind of people who find the program helpful, it is not a compelling reason to say the treatment will work for all addicts. When you further narrow the field by choosing an arbitrary definition of “success” — three years clean, or five, or ten — the end result is that the 12-step program works for a very, very small percentage of the total addicted population. 12-step centers then go on to hire exclusively from this very small pool. What this means is that, although the whole point is to show patients that they, too, can become “successful” like the staff has, the reality is that it is very unlikely any particular patient will be part of the same tiny percentage of the population that all of the staff are drawn from. (It is also worth noting that when I say “very small”, I don’t mean that the total number of successes is small. It might be several million; that doesn’t matter. All that matters is that, for every success, there are many millions more addicts who 12-step programs would call a failure.)

So the “inspiring” message that patients can become like the staff is likely very  misleading. What can make it harmful, though, is a fact of human psychology; human beings tend to find anecdotes more convincing than data. Especially to patients in a treatment center, who are often sick and frightened, a personal story of redemption told by an authority figure (a counselor or administrator) is much more powerful than a presentation on statistics of the kind I’ve discussed.

This is a very well-known fact of how human brains work, and there’s no getting around it. It’s the reason people buy lottery tickets, or refuse to fly on airplanes, or do any number of things that don’t make much sense from a statistical point of view. It can sometimes be very helpful to our survival, but it can also do us a great deal of harm. I personally have had patients leave my practice because I have statistics, data, FDA reports and medical science behind me, but I can’t offer a personal anecdote of having been at “rock bottom”. This emphasis on personal stories means that, not only are patients in 12-step treatment centers being told stories that are unlikely to apply to them, they are being taught to trust those stories more than any hard data they might see in the future. For the vast majority of people who won’t turn out to succeed in 12-step programs, the anecdotes they heard from ex-addict staff may prevent them from seeking other methods of treatment that might work better for them. It sends them back into ineffective 12-step programs again and again, utterly convinced that they can overcome all odds, projections,and medical facts, just because they heard that some other person once did (or thought they did).

While it may seem heartless to say that people shouldn’t try to beat the odds, the fact is that the odds are there for a reason. Moreover, acknowledging the facts and acting accordingly will almost always lead to a healthier and happier life for the larger number of patients.

We at the Bel Air Center for Addictions hope that all of you have a healthy and happy New Year.

Pain and Addiction

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This week, an excellent article on the American Pain Foundation (APF) was brought to my attention. In it, the APF’s stance that “the risk of [opioid] addiction is overblown” is examined in light of the fact that the APF receives a great deal of its funding from companies that produce addictive painkillers.  I highly recommend you click that link; the article is thorough and well-researched, and provides a valuable perspective on the kind of misinformation that can harm patients when medical issues become overly profit-driven. The companies producing and promoting the use of addictive painkillers clearly have financial motives to conceal their potentially harmful effects, and they also have clear motives for funding institutions such as the APF, which can lend credibility to research that might otherwise appear “scant or disputed”. Whether or not the people working at APF believe what they say about the “low risk” of opiate addiction — and despite the real good that APF may have done in the realm of patient advocacy — maintaining that prescription of opiates should be uncontrolled is severely irresponsible.

Will Rowe, the chief executive of the APF, is quoted in the linked article as saying that “The problem isn’t opioids… It’s poorly trained doctors who prescribe them too easily or in excess.” That is certainly true. No drug in and of itself is “good” or “bad”; all treatments are appropriate in some situations while being inappropriate in others. But Rowe and others similarly associated with the foundation also express fears that regulation of physicians will “scare them away” from prescribing opiates, and induce “opiophobia” that will harm patients.

Even if the fear of “opiophobia” is legitimate, I have a hard time believing that encouraging doctors to be more conservative in prescribing highly addictive drugs will cause more harm than it will prevent. What pain management doctors don’t seem to realize is that addiction is a distinct disease, and that some symptoms of what they think is “chronic pain” are, in fact, symptoms of addiction. Some patients absolutely do have chronic pain that requires long-term opiate treatment, but I would argue that many more patients have “chronic pain” which is actually chronic withdrawal. I have had more patients than I can count who, after a few days on buprenorphine, tell me that the underlying cause of their opiate use (back pain, joint pain, or other common pain conditions) has disappeared. In these patients, the initial problem that caused them to seek treatment for pain probably cleared up long ago, and that the pain they had been self-medicating was in fact withdrawal.

Patients who are addicted without knowing it, and who self-medicate for withdrawal, are among those most harmed by the APF’s insistence that opioids have “low risk” and must be protected from regulation. These substances are absolutely, unequivocally addictive, and downplaying that risk is an appalling betrayal of trust on the part of the APF and all similar institutions. Whether patients are willing to take that risk is a matter to be decided with their physicians, but that decision cannot be made well if both physicians and patients are assured that there is no risk.

I’ve written before about how more regulation on the prescription of pain pills could very easily decrease addiction (and its associated costs), choke off the supply of narcotics being sold illegally, and improve pain management by not compounding pain with further addiction-related problems. The APF’s stance against such regulation seems to me to be blatantly self-serving, which undercuts their claim to be focused entirely on patient welfare.

The Gold Standard

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On this blog I tend to talk about opiate addiction more than any other kind, mostly because opiate-addicted patients are the ones I most often see and treat. Of course, we can still learn from other kinds of addiction — in fact, if we really want to look at a powerful model for the disease of addiction, we need to look back at the gold standard: smoking.

There is very little actual advantage to smoking a cigarette, not in the way that there is for other drugs. It does not give you a lasting or euphoric high; it is not a great way to party or relax after hard week at work; it does not have nearly the psychoactive effect of any other typically abused drug. It can be a social activity, but more and more restaurants, hotels, and even public parks and bars have been banning smoking in recent years; smoking is becoming less and less feasible as a means of social connection, like alcohol is. The nicotine itself, apart from its addictive effects, provides a minimal amount of relaxation or stimulation (depending on how it is smoked) that literally lasts only for seconds.

So why do people smoke, and why do they continue to smoke after it becomes costly, inconvenient, and even life-threatening? The answer, of course, is because of nicotine’s addictive effect on the brain’s reward system. People become so addicted to this short-lived effect that they find it necessary to reproduce it hundreds of times per day. A one-pack-per-day smoker is smoking 20 cigarettes each day, perhaps taking between 10 to 15 puffs per cigarette. That equals 200 to 300 hits per day. The effect on the brain of a single hit of nicotine lasts about 4 seconds. 250 hits per day gives 1000 seconds, or slightly less than 17 minutes of nicotine-stimulated brain activity per day. If someone smokes their one pack a day over a typical 16  hours of being awake, each day they are providing nicotine to the brain for only 2% of their waking hours.

Now think about the cost that society and individuals pay for this addiction in years of life lost due to cancers, chronic lung disease, premature heart disease, etc. On average, smokers die 13 to 14 years earlier than nonsmokers. (You can check out some of the tobacco statistics here.)

Smokers are exactly like anyone addicted to any other drug. They aren’t weak, and they aren’t bad people. To non-addicts, it looks like they are constantly, continuously making an irrational choice, but that’s not the case. Their brains have simply become so dependent on those little bursts of nicotine that it is incapable of putting any long-term health or financial consequences before getting the next hit. The very fact that it’s not so obviously harmful, and that it generally takes years to start showing negative health consequences, allows smoking to escape a great deal of the stigma of other addictive drugs. While it’s true that no addict should be stigmatized for their illness, that also doesn’t mean that smoking should get a pass, or be considered ‘not a problem’, when it can be just as powerful a controlling force in an addict’s life as a stronger opiate.

Cigarette smoking is less extravagantly destructive than heroin or methamphetamine, but it follows the same pattern of all other addiction. These are all different forms of a single disease. Our current scientific advances in the treatment of addiction notwithstanding, the best way of dealing with addictions is still with education and prevention, so that they never start in the first place.

Thanksgiving Thoughts

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The blog is updating a little late this week because of the holiday. I hope that you all had wonderful Thanksgivings, and that you got the opportunity to spend time with your families and think about the things in life you’re thankful for. Though eating and shopping have become large traditional parts of this weekend, it’s always worthwhile to stop and reflect on what we are grateful for in our lives.

It’s always difficult to feel thankful when you’re suffering from a long-term illness, and the disease of addiction has a uniquely destructive effect on the lives of those it afflicts. The behavioral and psychological aspects of the disease often lead to broken families, as theft, lies, and betrayal take their toll on relationships with parents, spouses, and children. The financial drain of drugs and treatment can prevent addiction patients from being able to provide a large Thanksgiving feast. It’s a long, hard road to emerge from this disease, and it’s difficult at any point to feel particularly thankful for the troubles it brings.

But there are still reasons to be grateful. We now live in one of the few decades in history where an effective treatment for addiction is generally available. That treatment is not a cure, and it is not as widely available as I would like, but there is more hope of a normal life for addicted patients than there has ever been before. With more understanding of and education about this disease, the family members of addicted patients can learn to help their suffering loved ones and make treatment easier. And it is my sincere hope that understanding and treatment will only continue to improve.

Thanksgiving is now over, but I think it is worthwhile to remember what we have to be thankful for every day of the year. I am thankful for the ability to help my patients, and I will continue to reflect on that opportunity on Monday. Until then, I wish you all happy holidays.

Studies and Blame

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A study was published in the Archives of General Psychiatry this week with the aim of determining the effects of counseling on addiction treatment with and without maintenance medications like buprenorphine. The results and the response to the study were, for me, completely unsurprising. The abstract linked above reported that counseling had no significant effect on patient recovery at any stage of research, and that treatment with buprenorphine and naxolone produced a tenfold increase in the number of patients with “successful outcomes”. Once medication was tapered off, success rates returned almost to baseline (8.6% successful outcome, compared to 6.6% successful before beginning medication). The study concludes that “[p]rescription opioid-dependent patients are most likely to reduce opioid use during buprenorphine-naloxone treatment: if tapered off buprenorphine-naloxone, even after 12 weeks of treatment, the likelihood of an unsuccessful outcome is high, even in patients receiving counseling [...].”

The results of this study are unambiguous. It is concrete evidence for what I have been saying to my colleagues and patients for years: counseling, while it has its place in patient care, is not a sufficient or even particularly effective  treatment for the medical condition of opioid dependence. This is not revolutionary or counter-intuitive. There is no chronic medical condition on Earth that can be cured by counseling alone. Neither high blood pressure nor diabetes would show a counseling effect if tested in a similar study. Yet officials in the field of addiction continuously demand counseling as the sign of a valid treatment strategy.

What really surprises and upsets me about this study is the reaction to it, as expressed in this article from Addiction Professional. The very first paragraph of the article cautions that because the results for counseling were “disappointing”, the study required a “careful read” and in fact “should not be interpreted as diminishing any role for talk therapy”. Never mind the fact that counseling has been empirically shown to be ineffective when not combined with a well-informed medical treatment strategy; never mind that, even before this study, counseling-based addiction treatments have had abysmal success rates for decades. None of that is any reason to think there might be a diminished role for talk therapy!

I do happen to think that talk therapy should take diminished role in addiction treatment, but that isn’t even the most upsetting part of the article. It goes on for several paragraphs to express surprise at the fact that, once the medication was taken away from the patients, many stopped doing well; this culminates in one of the final sentences, in which a quote from Roger D. Weiss of Harvard Medical School blames the patients for the failure of counseling to make a good showing in this study.

Weiss’ quote implies that the counseling failed to make a difference because “[Patients] wanted the medication — that’s what they were there for.”

This trend, of blaming patients for not wanting to improve, is a despicable and predatory practice that goes back to the earliest days of addiction treatment, and would never be tolerated in any other field. It’s one I have written about a great deal, so I won’t go into again here, except to say that a more medication-based approach to addiction treatment would do a great deal to weed this idea of sickness as a moral failing.

The study published this week did a great deal to advance the study of addiction treatment, and it is my fervent hope that as time goes on this data, like all empirical data, will be used to create a more effective and comprehensive system of treatment in this field.

A New War on Drugs

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A great deal is made of the ‘War on Drugs’ in this country, and while it’s important to try and keep illegal drugs from falling into the wrong hands where they can be used for harm, there’s a much easier and possibly even more important battle over drugs that we simply aren’t fighting.

I’ve mentioned the epidemic of pain pill abuse a few times before on this blog. Prescription narcotics rank among some of the most addictive substances, activating exactly the same systems as heroin and cocaine. While they do have legitimate uses, they also have a huge potential for abuse — one that very few doctors, legislators, or even patients seem to be aware of. And while I’m always in favor of educating people about the nature of addiction, the epidemic of pain pill abuse has passed the point where education alone will be enough to stem the tide. It has been reported that 3% of the nation’s physicians supply more than 67% of the pain pills, a vast number of which get diverted, or are taken because of addiction rather than chronic pain. Those 3% of physicians must be aware that at least some of their patients are inappropriately dependent on the medication, and yet no attempt is made to limit it. No, education alone is no longer the answer in this battle against rampant abuse of drugs.

Thankfully, this battle isn’t one that requires actual violence, like the devastating fighting that can occur when police try to seize quantities of dangerous illegal substances. Fighting pain pill abuse won’t require us to police the nation’s borders against well-armed cartels of smugglers and profiteers. We know exactly where the the massive supply of inappropriate pain pills comes from; the prescription pads of physicians. Every prescriber of these pills is registered as a physician, and is a well-known figure in their community. All it would take to fight this epidemic is a few sentences written into the law restricting overprescription of painkillers, and a few DEA agents with a computer. That’s all it would take to essentially shut off the supply of prescription pain pills that are being diverted or taken inappropriately. Physicians who prescribe buprenorphine for addiction are limited to 100 patients each; if we exceed that limit, the DEA comes calling. How is it, then, that while we are kept strictly to our limit, other physicians can write for thousands of patients to get an unlimited number of painkillers, without any monitoring of progress or tracking of prescriptions? Take Michael Jackson’s death as an example. How was it possible for a single physician to order that many medications without a single red flag going up anywhere in the records of some pharmacy or pharmaceutical company? How is that no one every questioned him? If all the medications were for a legitimate course of treatment, they needn’t have been stopped, but it should at least have been looked into. The lack of oversight when it comes to prescription painkillers is appalling.

I understand that government intervention is often inefficient and can easily go wrong, but in this case it is vitally necessary. I have had more than one patient who was caught scamming my office, taking buprenorphine prescriptions while also going to another doctor for narcotic pain pills, either to take them in conjunction with buprenorphine or sell them on the street. These patients are usually discovered via the pharmacy, the point where their two prescriptions interact. The thing we need to do, then, is get the pharmacies on board and begin tracking some of these prescriptions from the point of sale. Obviously we need to protect the availability of narcotic medications for all those who need them for legitimate purposes, but there also needs to be some effort to control what is, in fact, a dangerous family of substances with therapeutic potential. Our current strategy — completely unrestricted flooding of the market — is resulting in nothing but widespread addiction, overdose, and massive diversion of prescribed medications.

Good Drugs and Bad

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I’ve talked before on this blog about the fear patients and physicians often have that treating addiction with buprenorphine is “only trading one addiction for another”. While this might technically be true, it’s a phrase that ignores the huge material and medical improvements to patients’ lives that buprenorphine gives by eliminating the high-withdrawal cycle of active drug abuse. (Not to mention putting a stop to the destruction of the brain and other organs by toxic substances.)

The problem here is that there are a lot of fine distinctions between the normal course of the disease of addiction and the controlled, symptomless “addiction” of buprenorphine, but people who don’t know a lot about the field of addiction medicine aren’t likely to see that. And it’s mostly people who don’t know about addiction medicine — voters, lobbyists, abstinence care providers — who control the way it is seen by the public and dealt with by the law.

There is a similar confusion I often hear about “prescription drugs”. Lots of people know that misuse and overdose on prescription narcotics cause a huge number of deaths every year. There’s a general sense that we have to reduce the number of drugs being prescribed, because more drugs leads to more death. So when physicians like me who realize the need for medication treatment of addiction try to push for the power to prescribe more medication, we are met with resistance from the belief that prescription drugs kill people, and are bad.

While this is an understandable response to the amount of drug deaths we see yearly in the U.S., it is also an overgeneralization that actually does a great deal of harm to everyone involved. It’s true that many kinds of prescription medication, especially narcotics, can be and are abused. It’s true that patients often scam multiple doctors to get prescriptions for these kinds of medications, and that the best way to cut down on their abuse would be to keep a stricter watch on prescriptions and reduce the number of prescriptions given out. So how can I advocate for wider prescription?

There are several very important distinctions that “prescription drugs” fails to acknowledge. The first, and maybe most important, is that it’s virtually impossible for a patient who is already addicted to opiates to lethally overdose on buprenorphine. Once the opiate receptors are fully saturated, taking more buprenorphine will have no appreciable effect. So while it can certainly be diverted to the street and shouldn’t be given out indiscriminately, buprenorphine is infinitely less dangerous than ordinary prescription narcotics and benzodiazepenes. It also carries fewer health risks in and of itself than many stronger opiates.

Secondly, buprenorphine by definition is a medication used to treat addiction, and therefore would only be prescribed by physicians who are knowledgeable about treating the disease of addiction. It’s my opinion that the root of our prescription painkiller problem today is physicians who don’t know or don’t understand the addictive effects of the medications they prescribe, and aren’t willing to deal with the addictions of their patients. Over-prescribing of opiates and narcotics has led to a rise in the incidence of the disease of addiction, and now new, different medications are required to treat this disease that we created.

A good way to think about this problem is by analogy to viruses and vaccines. It seems non-intuitive at first that exposure to a virus could help you avoid the problems caused by that virus, but that’s exactly how vaccines work. It’s also how buprenorphine works; by introducing a safer, more predictable, more controllable version of the problematic prescription drugs, we can prevent and alleviate the problems they cause, from crime rate spikes to the deaths of celebrities.

There is no such thing as a “good drug” or a “bad drug” — all drugs can be good when they’re given and taken in the right circumstances, and all drugs can be bad when they’re abused. Saying that all prescription drugs are bad is a shortsighted assumption that can do long-lasting damage to patients and physicians alike.

Moral Lessons

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Last week on this blog I shared the story of one of my patients, and how her situation illustrates that the truth is never simple, especially not when it comes to healthcare and the management of debilitating diseases. This week I want to talk about the same complexity from the treatment side of the problem.

12-step programs are often concerned with addiction as a “spiritual and moral” disease, instead of (or in addition to) a physical condition. Most 12-step programs incorporate moral lessons into their treatment plans. Possibly the most common moral lesson, and one of the most important, is the idea of “letting go”, of turning control over to a Higher Power, which is almost always synonymous with God. The point of this step is to “teach” humility and help patients to “let go of their pride”.

Humility is one of the core values that 12-step programs try to impart to their patients. Yet, looking to the people and organizations who run the 12-step programs, humility doesn’t seem to be among their core values. Each and every 12-step program insists that it is the only possibly path to recovery, that it is the only one capable of giving patients the wisdom they need to overcome their “spiritual” shortcomings. The plain truth of the matter is that no particular model can show recovery numbers that stand out; nearly all have a very low overall recovery rate. Those that can boast more impressive recovery rates can usually only do so to the extent that they include treatment of addiction’s physical causes in with their “spiritual” treatments. This is because teaching moral values, even good moral values, won’t help cure someone of a physical disease. To people who are sick and suffering, the message often won’t even get through.

It’s easy to see why each needs to paint itself as the only one that works; in a market where no one product is distinguished by superior quality, everything depends on marketing to convince potential customers to choose them. It’s a ploy, one that can play on a customer’s need to feel that they are getting exclusive or secretive treatment, that not everyone has access to. In the worst cases, it’s little more than a snake oil pitch.

But again, we have to remember that the truth is never that simple. Many people who run and participate in 12-step programs honestly believe that their’s is the best, perhaps because they went through it successfully, or knew someone who did. There are any number of ways that passionately convinced people can dismiss or argue against numbers that indicate a pretty standard failure rate across programs. It can be difficult to see the faults of a system while you’re in the middle of it.

I don’t support the methods 12-step programs use to treat their patients, or the hypocrisy that the 12-step business model seems to make necessary. AA and NA, since they are nonprofit and therefore aren’t competing for customers, are much less dependent on this sort of “marketing”; they function more as amateur community support groups. There is certainly a place in the field of addiction for such support groups, although they should never be the primary form of treatment.

12-step programs make money by selling a system of morality to their customers — a system which their own business model often makes impossible for them. It’s always difficult to negotiate a relationship between medicine — the relief of human suffering — and money; the American government is seeing the fallout from a poor medicine-money relationship right now. But a business model that encourages lying to customers in order to convince them to choose one service over another is predatory and should not be allowed to continue.

Simple Truths

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The truth is never simple.

This week, I discovered that one of the patients in my office is a drug dealer. While she is seeing me for her opioid addiction and getting buprenorphine prescriptions, she continues to see her regular doctor to get prescriptions for her narcotic pain pills. She then sells the narcotics on the street. She is defrauding her insurance company, lying to multiple doctors, and enabling other addicts by illegally making prescription narcotics available to them.

She is also a 76-year-old grandmother, widowed, and barely able to walk due to scoliosis — the reason she was taking addictive prescription narcotics in the first place. She lives with her son, who helps to take care of her. Both this woman and her son are on Medicare and disability, and her profits from selling narcotics are a significant part of their income and is absolutely essential for them to make ends meet.

Selling drugs is criminal and morally wrong; in addition to harming those who buy the drugs, it has long-lasting consequences on the entire healthcare system. “Diversion” — when prescription drugs are sold on the street rather than being taken as prescribed — is a major issue in pain management and addiction right now, and it’s one of the reasons that many physicians are so reluctant to treat addicted patients.

The selling of drugs illegally also reinforces the connection between substance addiction and crime; it familiarizes younger addicts with criminal behaviors, but also casts undeserved shame on people who have never committed a crime but are addicted to prescription narcotics due to illness and injury, like this woman herself.

Clearly what my patient is doing is wrong — but saying she is “weak”, or a bad person, becomes difficult. Here we have a woman who is desperate and disabled, just trying to survive. The Occupy Wall Street movement which has recently spread throughout the country is teaching us just how much desperation and anger exists among people trapped in poverty and unemployment, and how desperate situations can lead to desperate acts. The Occupy movement has been ridiculed for not having a clear agenda or offering solutions to America’s financial problems, but this is foolish, and it’s a distraction from the really important thing; that it doesn’t matter whether Occupy Wall Street has a clear agenda. What matters is that it is happening. People are spontaneously gathering all over the country to express their frustration with the economy. That this is happening at all is a clear sign that this country’s social, economic, and medical systems are massively, disastrously broken.

My patient is not connected to the Occupy Wall Street movement, except for the fact that her situation is a symptom of a massively broken system. Just the fact that she is forced to sell her pain pills in order to make ends meet is a sign that something has gone terribly wrong in the Social Security systems meant to keep her out of poverty, and the medical systems that are meant to effectively manage her treatment.

Her terrible situation does not excuse her from the responsibility of the harm she’s caused by selling illegal drugs. All talking about it can do is help others understand the root of the problem, which is the only way we as a society might have a hope of solving it. And if nothing else, this goes to show just one more way in which the public, “commonsense” perception of drugs, drug addicts, and even drug dealers is far too simple, divided, and prejudiced to approach the deeply complicated truth.