A Court Rejected the Disease Theory of Opioid Addiction. Will We Listen?

November 22, 2021

The idea that opioid painkillers are inevitably addictive was put on trial and refuted. But this modern disease theory seemingly can’t be extinguished as long as it is granted “scientific” credibility by prominent experts and unquestioned acceptance by the media.

A 2016 book by Stanford addiction expert Dr. Anna Lembke—Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop—presented the hard-core, sinister case against drug companies. It’s a case firmly rooted in her view of opioid addiction as an irresistible, irreversible disease.

Meanwhile, the recent, high-profile Hulu series Dopesick is based on the 2018 bestseller by Beth Macy, a journalist who investigated the drug crisis in Appalachia. Macy’s book—Dopesick: Dealers, Doctors and the Drug Company that Addicted America—tells essentially the same story as Lembke’s. The company in question is (or rather, was) Purdue, run by the Sackler family.

The book and series maintain that Purdue/the Sacklers lied that OxyContin was rarely addictive. Instead, people frequently became hooked, and died, because addictiveness is an inherent property of opioids.

Hulu’s Dopesick aims for a feeling of authenticity by, for example, portraying a doctor who had been addicted to OxyContin.

Opponents of the disease model certainly don’t deny that many people become addicted to opioids and other drugs, as well as to powerful non-drug behaviors and experiences. Addiction is fundamental to human experience.

But pointing out the genuine addictive experiences of individuals like Dopesick’s doctor doesn’t shed light on the likelihood of becoming addicted to opioids.

Indeed, we know that likelihood is quite low.

Earlier this month, a court painstakingly ascertained just that, along with dispelling a litany of headline-grabbing claims about opioids 

 

A Court Rejects Lembke’s Arguments

Unlike Macy and Dopesick’s other producers, Lembke is highly credentialed—a psychiatrist, director of the addiction medicine clinic at Stanford University, and a TED speaker. She is thus deemed qualified to offer expert testimony in court.

On November 1, Judge Peter J. Wilson, in Orange County’s California Superior Court,  issued a ruling in a case brought by four California jurisdictions against numerous opioid manufacturers over their alleged liability for causing addiction and many resulting deaths.

His ruling: “There is simply no evidence to show that the rise in prescriptions was not the result of the medically appropriate provision of pain medications to patients in need.”

The court rejected the plaintiffs’ claims, which were based primarily on Lembke’s testimony, finding her and the suing jurisdictions to be plainly wrong in four ways: overstating the incidence of prescription opioid addiction; ignoring the medical benefits of opioid pain relief; generalizing inappropriately from drug death “hot spots” to less severely affected jurisdictions; and failing to show that prescribing practices caused the crisis of opioid-related deaths.

Below are several illustrative quotes taken from an interview with drug manufacturers’ attorneys John Heuston and Moez Kaba, together with excerpts from the judge’s decision.

Hueston: “[The key factor] was Stanford professor Lembke. Dr. Lembke was presented as the lead voice by the plaintiffs for their case trying to establish [drug company] misstatements that drove the crisis in California.”

Kaba: “It’s an extraordinarily methodical order. He [the judge] goes through alleged statement after alleged statement and reaches the findings that these are not false statements …”

“The studies relied upon by Dr. Lembke for that conclusion are inadequate to support it.”

The judge, who regularly stopped the trial to hold detailed discussions about evidence, noted in his ruling that Lembke “testified that one in four patients prescribed opioids would become addicted.”

But, he continued, “as Defendants point out, the studies relied upon by Dr. Lembke for that conclusion are inadequate to support it … the more reliable data would suggest less than 5 percent, rather than 25 percent.” And even with that much lower figure, “addiction based solely on the patient having been prescribed opioids does not occur in ‘most of these patients.’”

Kaba: “One of the things that Dr. Lembke claimed, for example, was that it was false or misleading to suggest that opioids can improve the function of people who take them. And we had her admit very clearly, very plainly, that not just the FDA but the state of California itself in its own laws acknowledges that opioid medications when properly prescribed do, in fact, improve function.”

Defense attorneys were also at pains to contextualize the California jurisdictions’ claims. That is, opioid addiction and death rates are highly dependent on specific locales and social settings.

Defense attorney Hueston: “We certainly wanted to make sure that a case about the opioid epidemic in California actually related to California. And what we wanted to do was to anticipate and blunt the attack from plaintiffs that California is like Appalachia and Tennessee, or some of the other notorious hot spots.”

Kaba: “There’s another part of his order where he says that there’s no causation, which was another big part of our case. In the examination that [Heuston] did of our economist, we proved that there is no causation …”

Proving causation requires linking more prescriptions to greater addiction and death rates. In fact, while there has been a steady decline in painkiller prescriptions, by nearly half, from 2012 to 2020, drug deaths continued to achieve record levels over that period, more than doubling between 2015 and 2020 alone. Causality—if anything—seemingly flows in the opposite direction. That is, restricting painkiller prescriptions leads to negative outcomes.

 

An Assault on Chronic Pain Patients

The trial additionally highlighted patients’ right to pain relief, and how the disease theory of addiction attacks this right.

Organizations representing pain doctors have strongly objected to draconian limitations imposed on prescribing. The American Medical Association itself has passed “resolutions against the rash of laws and mandatory policies that limit or prevent patient access to opioid painkillers.” Beleaguered pain patients have organized themselves into a grassroots movement.

Heuston: “It was critical to our strategy to ensure that the voices that are in support of proper pain management were heard, that pain management doctors who could help describe the life crises of people who simply have inadequate treatment of pain … the judge’s opinion sets forth not only the understanding of that balance by the FDA and the federal government but how that is enshrined specifically in California in, for instance, the Patients’ Bill of Rights.”

Stanford Medical School and its hospitals, incidentally, subscribe to these rights, including that to opioid medication.

Little wonder that this month, a group representing people with arthritis and rheumatic disease, whose leadership had invited Lembke to present to it, rescinded its invitation: “We understand how some of Dr. Lembke’s previous work and comments can be problematic. Thank you for taking the time and energy to show us articles, interviews, and quotes from Dr. Lembke that are not in keeping with our mission at CreakyJoints.”

 

Drawing the Wrong Conclusions From Vietnam

The 2020 Netflix series The Pharmacist jumped from a drug-related murder in New Orleans to portray an overwhelming national epidemic of prescription-opioid overdoses due to addiction. This view is put forward in spite of the dominant roles in today’s unprecedented drug-deaths crisis of drug-mixing, of an illicit supply adulterated with fentanyl and its analogues, and of the policies that lead to these conditions. (Due to this toxic combination of factors, it is actually a misnomer to label the deaths simply as “overdoses.”)

Dr. Lembke was interviewed in the Netflix series. “This country has seen two prior opioid epidemics,” she said, citing the Civil War and “when soldiers were coming back from the Vietnam War.”

Most soldiers who used heroin didn’t become addicted, and the overwhelming majority of those who did quickly recovered stateside, without treatment.

But the Vietnam addiction story actually demolishes Lembke’s opioid disease model. As Zach Rhoads and I described in Filter, “Vietnam Vets Proved that Addiction is a Product of Life Circumstances.”

Most soldiers who used heroin didn’t become addicted, and the overwhelming majority of those who did (over 90 percent) quickly recovered stateside, without treatment. The small group whose addictions persisted were identified by their adverse social situations before and after the war.

In 2021, 50 years after Lee Robins’s iconic Vietnam research, science journalist Lauren Aguirre revisited “Lessons learned—and lost—from a Vietnam-era addiction study … It’s too bad this research has been largely forgotten because its lessons can be useful today.”

As Aguirre notes, “many people recover on their own from drug addictions … most of them did not receive formal treatment.”  Furthermore, “exposure to opioids doesn’t inevitably lead to a substance use disorder. Some people can use opioids occasionally without becoming addicted [this included veterans who had been addicted in Vietnam]. In fact, a recent analysis found that only about 3 percent of the tens of millions of people prescribed opioids become addicted.”

In this context, Netflix viewers were led to think that the Vietnam narrative supports Lembke’s (and Dopesick’s) underlying assumption of the inescapability of addiction. But their perspective—which dominates the popular and political discourse—is actually the reverse of the meaning we should have taken from the Vietnam opioid experience.

 

Media Boosting of the Disease Theory

Media of all kinds and all political stripes are typically stalwart presenters of the Dopesick/Lembke demonization of opioid painkillers. Joe Rogan (who interviewed Lembke*), PBS’s Christine Amanpour (who interviewed Macy), and MSNBC commentators (several of whom interviewed Dopesick producer Danny Strong and showed clips from the series) are just a few examples of the worshipful exposure media give to inaccurate suppositions about opioids.

Hulu promoted a clip from Dopesick in which a tearful Appalachian doctor says that most of his patients became addicted. MSNBC’s Joe Scarborough and Nicolle Wallace, to name two, eagerly endorsed this preposterous claim.

It is our obligation to firmly and finally reject the demonization of drugs—including portraying addiction as the inexorable, irreversible, unavoidable consequence of drug use.

Most media’s ignorance of drug issues has long been a given. More exasperating is when people who support drug policy reform implicitly endorse the disease theory. I recall one event in 2017, at which figures from New York government, public health and several harm reduction organizations celebrated successful efforts to reduce painkiller prescribing since 2012—while simultaneously depicting continually rising drug-related deaths over the same period.

It is our obligation instead to firmly and finally reject the demonization of drugs—including portraying addiction as the inexorable, irreversible, unavoidable consequence of opioid and other drug use.

Many harm reduction and reform advocates rightly focus on the critical role of the social, psychological and economic circumstances faced by people who experience drug-related harms. They understand that drug use is not an infection. It is both a normal behavior and a human response to distress. And they see drug use as a human right, and drug users as a constitutionally protected group.

We will never contain our epidemic of drug deaths until these anti-drug war, anti-disease realizations are more widely shared.

 


 

Photograph by K-State Research and Extension via Flickr/Creative Commons 2.0

*I discuss, in “The Dope on Dopamine,” Joe Rogan’s podcast with Lembke about her 2021 disease follow-up, Dopamine Nation, which implausibly reduces addiction to neurochemistry.

Stanton Peele

Dr. Stanton Peele is a psychologist who has pioneered, among other things, the idea that addiction occurs with a range of experiences and recognition of natural recovery from addiction. He developed the Life Process Program for addiction. He has authored many books since the 1975 publication of Love and Addiction (co-authored by Archie Brodsky); his latest is A Scientific Life on the Edge: My Lonely Quest to Change How We See Addiction.

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