Drug Dealer Md by Anna Lembke – Summary With Notes and Highlights

📕 Book Summary in 3 Sentences

What can I say about the book in 3 sentences?

1. The prescription of highly addictive medication to patients by well-meaning doctors. The patients then become dependent and addicted to these medications.
2. The brain as a scale managing happiness by staying in a balance
3. No matter what we do to be happy or sad, our brain will always bring us back to a balanced state where we are neither happy nor sad.

🤔 Major Insights/Ideas

What are the major insights or ideas in the book?

1. Insight 1: The prescription of addictive medication such as Adderall and Valium to patients by well-meaning doctors. The patients then become dependent and addicted to these medications. Subsequently, their prescribed medication comes to destroy their lives.
2. Insight 2: Criteria for addiction is remembered as the 3C’s
   1. Control – when the substance is used at any point in time
   2. Compulsion – there is an emotional drive to use or acquire the substance
   3. Consequences – where the person sweeps aside the social, cultural, or economic problems arising from the addiction
3. Insight 3: A person can become physically dependent on a drug to a point where they cannot function without it
4. Insight 4: Our environment plays a strong role in whether we take drugs or not. If there is the availability of drugs in our neighborhood, we are more likely to try them.
5. Insight 5: Who gave birth to us also plays a role in whether we become addicts or not. If your parents or grandparents were addicts, you would likely become an addict.
6. Insight 6: How we are raised is another element that plays a role in whether we become addicts or not. If drinking or smoking is encouraged in our family, we are more likely to become addicts.
7. Insight 7: Adolescence is the most dangerous time to take drugs. Because the brain is changing, taking drugs can inflict irreparable damage to your cells.
8. Insight 8: The brain can be viewed on a scale. It is always trying to balance itself. A state where we are neither happy nor sad. When eating a bar of chocolate. We become happy. The brain then produces hormones to delete this rush of dopamine. In a short period, we will be back to a balanced state. For instance, we have all experienced a feel-good rush buying a new iPhone. Only to forget about the feeling in just under an hour.

💬 Notable Quotes

What are your top quotes?

• We know now that opioid painkillers prescribed by a doctor are as addictive as heroin purchased on a street corner.
• Denial is the refusal to accept a threatening reality by simply believing it doesn’t exist.
• Denial means – Don’t Even kNow I Am Lying – Alcoholics Anonymous.

✍🏼  My Personal Reflections

How has your life/behavior/thoughts/ideas changed after reading the book?

• I learned the ability of our minds to balance our good and bad days. The brain works to neutralize our sad days and good days.

💡Actionable Steps/Ideas (if any):

• We are more resilient than we give ourselves credit for. No matter how happy or sad we become, our brain will always bring us back to a balanced state where we are neither happy nor sad.

🔆 Book Highlights

1. The combination of opioid painkillers and sedative benzodiazepines (for example, Valium) has contributed to a large number of the overdose deaths
2. Equally alarming has been the increased prescribing of stimulants (for example, Adderall) and sedatives (for example, Xanax) over the last three decades.
3. The drugs posing the greatest risk for misuse, overuse, and addiction are the “scheduled” (controlled) drugs.
4. Schedule I drugs, according to federal classification, have no medical benefit and thus cannot be prescribed by a doctor under any circumstances.
5. Examples of schedule I drugs include heroin, lysergic acid brace yourself—marijuana. Despite federal classification of marijuana as a schedule I drug, it is widely available in more than twenty states through medical marijuana dispensaries, putting state and federal regulations in direct opposition.
6. Schedule II drugs include most of the opioid painkillers. Doctors can typically give no more than a month’s worth of schedule II medication at a time, with no refills allowed. Examples include morphine, opium, codeine, hydrocodone (brand name Vicodin), hydromorphone (Dilaudid), methadone (Dolophine), meperidine (Demerol), oxycodone (OxyContin, Percocet), and fentanyl (Sublimaze, Duragesic). Vicodin
7. Stimulants, which are also considered to be highly addictive, are in schedule II. They are most often used in the treatment of attention deficit hyperactivity disorder (ADHD) and include amphetamines (Dexedrine, Adderall) and methylphenidate (Ritalin)
8. Schedule III includes buprenorphine (Suboxone), ketamine, and anabolic steroids such as Depo-Testosterone
9. Schedule IV drugs include the important subgroup of the sedative hypnotics, so-named because of their use in the treatment of anxiety and insomnia
10. Benzodiazepines are a class of drug within the sedative-hypnotics, including but not limited to alprazolam (Xanax), clonazepam (Klonopin), diazepam (Valium), lorazepam (Ativan), midazolam (Versed), and temazepam (Restoril). Examples of other schedule IV drugs are carisoprodol (Soma) and zolpidem (Ambien)
11. Schedule V drugs consist primarily of preparations containing limited quantities of opioids. Examples of schedule V drugs include cough preparations containing not more than 200 mg of codeine per 100 ml (Robitussin AC, Phenergan with Codeine)
12. In 2014, the Drug Enforcement Agency (DEA) rescheduled tramadol to a schedule IV drug, thereby communicating its addictive potential to doctors and consumers. Tramadol when first ingested has limited opioid painkiller properties, but it is quickly metabolized by the body into a more potent, and hence addictive, opioid painkiller
13. This book is my attempt to understand how well-meaning doctors across America—most of whom became doctors in the first place to save lives and alleviate suffering—ended up prescribing pills that are killing their patients, and how their patients, seeking treatment for illness and injury, ended up addicted to the very pills meant to save them.
14. The DSM diagnostic criteria for addiction can be remembered simply as the three “C’s”: control, compulsion, and consequences.
15. Control refers to out-of-control use, especially using more of a substance than intended.
16. Compulsion refers to spending a great deal of time, energy, and thought (mental real estate) obtaining, using, and recovering from the use of substances.
17. Consequences refers to the social, legal, economic, interpersonal, and moral or spiritual repercussions of continuing to use.
18. According to these diagnostic criteria, Jim was certainly addicted to alcohol, with out-of-control use (drinking until he couldn’t drive himself home), compulsive use (progressing to daily drinking), and consequential use (losing his smog testing business)
19. Physiologic dependence is the process whereby the body comes to rely on the drug to maintain biochemical equilibrium.
20. When the drug is not available at expected doses or time intervals, the body becomes biochemically dysregulated, which manifests as the signs and symptoms of withdrawal.
21. Withdrawal is the physiologic manifestations of not having the substance, the symptoms of which vary from substance to substance.
22. As a general albeit oversimplified principle, the characteristics of withdrawal from a given substance will be the opposite of intoxication for that substance. For example, intoxication with alcohol includes euphoria, relaxation, lowered heart rate, lowered blood pressure (mild), and sedation (sleep).
23. Withdrawal from alcohol includes dysphoria (unhappiness), agitation, restlessness or tremor, increased heart rate, elevated blood pressure, and insomnia.
24. According to neuroscientists, addiction is a disorder of the brain’s reward circuitry.
25. Survival of the species depends on maximizing pleasure (finding food when hungry, for example) and minimizing pain (avoiding noxious stimuli). Seeking out pleasure and avoiding pain is adaptive and healthy.
26. The intense pleasure experienced with addictive drugs and importantly the memory of those pleasurable experiences and the desire to re-create them, is what prompts reuse.
27. Jim’s magical RV ride after passing his exam is a prime example of this. Indeed, many people who later go on to develop a substance use disorder describe a vivid positive experience with their early exposure to drugs or alcohol.
28. The individual who is vulnerable to addiction will commit all available resources to obtaining more of the substance, overcoming tolerance, and re-creating its original effect, even forgoing natural rewards like food, finding a mate, or raising children. Over time the substance itself is mistaken as necessary for survival.
29. What Makes Us is likely to take Drugs
30. decades of accumulated evidence point to certain risk factors, which can broadly be divided into three categories: nature, nurture, and neighborhood.
31. Nature. There is good evidence that vulnerability to addiction is heritable, passed down within a person’s genetic code from one generation to the next.
32. The data show that having a biological relative (parent or grandparent) with addiction increases the risk of becoming addicted, and that genetics accounts for between 50 and 70 percent of that risk a high percentage compared to the currently known genetic contribution in other mental disorders such as depression (30 percent).
33. Emotion dysregulation (experiencing emotions with more intensity and for longer than average duration) and impulsivity (the tendency to act on thoughts or emotions without weighing the consequences) have both been shown to be highly heritable traits, and are associated with the later development of addiction
34. Nurture. We know that children raised in families where using addictive substances is modeled and even encouraged, are at increased risk of developing a substance use disorder, as in Jim’s family. Substance use is more likely to occur in adolescents who affiliate with so-called deviant peers.28 Early childhood trauma increases the risk of addiction. High conflict between parent and child, lack of parental involvement in the child’s life, and lack of parental monitoring,29, 30 also appear to be developmental risk factors.
35. Neighborhood. The risk of substance use, and hence the development of a substance use disorder, is strongly related to the sheer availability of addictive substances. If an individual lives in a neighborhood where drugs are sold on the street corner, that individual is more likely to experiment with, and get addicted to, those drugs. The classic example of this is American soldiers in Vietnam, many of whom used heroin regularly while in Vietnam, but stopped or greatly curtailed their use after returning to the United States.
36. How do people stop using substances once they have become addicted to them? The neuroscientist Roy Wise, who studies addiction in animals, says that the only way an addicted animal will stop using drugs is if the drug is no longer available, the animal is too physically exhausted to administer the drug, or the animal dies.
37. More recent studies reveal that as many as 56 percent of patients receiving long-term prescription opioid painkillers for low back pain, for example, progress to addictive opioid use, including patients with no prior history of addiction
38. For increasing numbers of people, especially young people, prescription drugs are the first exposure to addictive substances and the first stepping-stone to future addictive use
39. Justin, like many teens today, especially compared with previous generations, had early exposure to scheduled drugs (opioids) through a doctor’s prescription, thereby developing a “taste” for them, followed by virtually unlimited access to drugs through peers at school and on the Internet
40. Prescription drugs now rank fourth among the most-misused substances in America, behind alcohol, tobacco, and marijuana; and they rank second among teens
41. Adolescence is a time when the rapidly growing brain is more plastic, and therefore more vulnerable on a neurological level, to potentially irreversible brain changes caused by chronic drug exposure
42. they were unaware that the pot Justin smoked was much more potent than anything his dad had access to in the 1970s.
43. The majority of new heroin users cite prescription opioids as their first exposure to opioids, a clear generational shift.
44. Increases in heroin use have been driven mostly by 18–25 year olds
45. For millennia, we have understood pain in our lives to serve at least two useful functions.
46. First, pain is a warning system: what to avoid and what not.
47. Second, pain is an opportunity for spiritual growth: “What doesn’t kill you makes you stronger,” “After darkness comes the dawn,” etc.
48. Today, pain is little valued for these reasons. Instead, modern American culture regards pain as anathema, to be avoided at all cost
49. The pressure to treat pain has become so overwhelming that doctors who leave pain untreated are not just demonstrating poor clinical skills; they are viewed as morally compromised. They are also legally liable for malpractice.
50. Karen arrived at college in 2005 with high expectations but without the support structure she was used to. The classes were huge, the material more challenging, and she had no more tutors to help her
51. Adderall is an FDA schedule II drug, which means that, although it has been shown to have medical benefit, it also has a high potential for misuse and addiction
52. In the absence of a cognitive disorder. Likewise, benzodiazepines (Xanax) help people relax in the absence of anxiety, sedatives (Ambien) induce sleep in the absence of insomnia, and opioids (Vicodin) enhance subjective well-being in the absence of pain
53. What is striking in our culture today is how readily those differences are labeled as illness and treated with a pill. From early childhood onward
54. Many of today’s youth think nothing of taking Adderall (a stimulant) in the mornings to get themselves going, Vicodin (an opioid painkiller) after lunch to treat a sport’s injury, “medical” marijuana in the evening to relax, and Xanax (a benzodiazepine) at night to put themselves to sleep, all prescribed by a doctor.
55. Recent federal legislation demands that doctors who receive financial reimbursement from a drug or medical supply company disclose those payments
56. We know now that opioid painkillers prescribed by a doctor are as addictive as heroin purchased on a street corner.
57. He was given a prescription for a one-month supply of Norco, a combination of acetaminophen (Tylenol) and the highly addictive opioid hydrocodone (the primary ingredient in Vicodin).
58. The drug-seeking patient is better understood through the lens of addiction. Addiction is an altered brain state in which motivation for basic survival has been “hijacked” by the drive to obtain and use substances.
59. Brain as a scale
60. The job of the scale is to register and communicate pleasure and pain. When the beam is tipped down to the left, the brain senses pleasure. When the beam is tipped down to the right, the brain senses pain. When nothing is on the platforms, the beam is level with the ground and balanced, that is, homeostatic, registering neither pleasure nor pain.
61. According to George Koob, a neuroscientist who has spent his career studying the neuroadaptive changes the brain undergoes with chronic exposure to addictive substances, the preferred position of the beam is level, in which neither side outweighs the other. To achieve and maintain this state of equilibrium, the brain is constantly adjusting and readjusting on a biochemical level. When an individual who likes chocolate eats a piece of chocolate, the metaphorical beam tips down to the left, communicating pleasure, mediated by release of the neurotransmitter dopamine. But the scale wants to be level again. To achieve a level state, metaphorical brain gremlins start jumping on the opposite side of the scale. This might translate into decreasing the amount of pleasure-boosting dopamine the brain makes or decreasing neuronal receptors that recognize dopamine. Hence the pleasure from eating chocolate is short-lived, and the beam is level again. The brain has now “adapted” to chocolate, and the second piece doesn’t taste nearly as good as the first one did.
62. When drugs and alcohol are consumed, the metaphorical beam tips much further to the left than it did with a piece of chocolate. The result is not just pleasure, but euphoria—a high. In the healthy brain, lots of brain gremlins have to pile onto the opposite side of the scale to balance it again.
63. Tincture of time (most often weeks to months) eventually allows all the gremlins to dismount the beam, at which point the beam is level, and homeostasis has been reestablished. But until that occurs, the only way some addicted persons will be able to arrive at that place is to be put in a restricted environment where they do not have access to drugs.
64. In a world in which the struggle for basic survival (food, clothing, shelter) has become largely irrelevant for most Americans, the ill person is among the last of the great warriors
65. Denial is the refusal to accept a threatening reality by simply believing it doesn’t exist
66. Denial means – Don’t Even kNow I Am Lying – Alcoholic Anonymous
67. This new doctor, perhaps humbled by Mike’s desperate admission, took Macy in and admitted her to the hospital, using the occasion to get her a treatment plan that included assessment and treatment for addiction, which had never previously been suggested or offered and which is how she eventually ended up with me