Prescription drug addiction: the dark side of concierge medicine

Addiction professionals who serve an affluent client population must be skilled in understanding and intervening on the sophisticated systems within which their clients operate. These systems contain dynamics that are consciously and unconsciously manipulated by the power inherent in the clients’ wealth, influence and celebrity. One of the most easily manipulated of these systems is the affluent client’s medical team.

Typically led by a concierge physician who is hyper-focused on providing exceptional service to her/his patients, these medical professionals are untutored in prescription drug addiction, and as such get unknowingly pulled into its dark abyss. In this article, I illustrate how the power inherent in this system plays out, and offer five suggestions to help addiction professionals artfully dismantle these forces.

The problem

“John” (the details of this case vignette have been altered to protect the confidentiality of my clients) is an heir to an industrial fortune with a pedestrian first name and an internationally recognized last. With homes in Manhattan, Aspen, Palm Beach and the Hamptons, he’s a fixture of the charity circuit, where his incredible generosity helps thousands of needy families each year. But while looking nearly perfect from without, John harbors a shadowy secret.

Sixteen months ago he underwent a total shoulder replacement from a world-renowned surgeon to correct an acute case of arthritis. Eighteen months prior to the surgery, his concierge physician began prescribing him oxycodone to manage the debilitating pain that accompanied this condition. John supplemented the prescription with medical marijuana that he purchased at an Aspen dispensary and “bone dry martinis” that his devoted wife of 37 years prepared for him nightly in their living room du jour.

During his surgical discharge, John asked the nurse for a prescription for Xanax “to take the edge off” his anxiety. Following protocol, the nurse denied his request, stating John’s “surgeon never sends his patients home with 'benzos' as the risk of abuse is quite high.” Minutes later, however, the surgeon modified his definition of “never” and handed John a prescription for 12 Xanax tablets (2 mg each). As he handed John the prescription, he also suggested that John meet with the hospital’s chief development officer for lunch to explore ways he can help out other, “less fortunate” patients.

Immediately after the surgery, John chartered a jet to fly down to Palm Beach, where he intended to spend the winter recovering. Realizing that by crossing state lines he could “double dip” and manipulate Florida and New York’s prescription drug monitoring programs (which monitor data about the prescription and dispensation of federally controlled substances), he secured a new panel of prescriptions in Florida while continuing to have his secretary fill his surgeon’s prescriptions in New York. Comfortably back in Palm Beach, John settled into his surgical recovery with an embarrassment of pharmaceutical riches.

The net result of this exceptional service was that John felt special (like a VIP), while his medical team believed it had earned its fees and the right to solicit John for a charitable donation. And although a completely satisfied customer, John traded a chronic condition that compromised the quality of his life for one that held the potential to end it.

As an addictions and licensed marriage and family therapist who specializes in behavioral health issues among the world’s elite, I’ve seen an explosion in the number of patients whose wealth, power and celebrity lead them into the devastating clutches of prescription drug addiction. What distinguishes this phenomenon is that these cases result not from some sinister act of malfeasance, but rather from the distorted judgment and lack of awareness of intelligent and accomplished medical professionals. Certainly, the most blatant example of this phenomenon is the tragic case of Michael Jackson. But for every case that becomes fodder for the tabloids, there are thousands more flourishing behind the gates and doormen of the world’s elite.

This isn’t to say that the practice of concierge medicine is ipso facto bad. To the contrary, concierge doctors provide an exceptional service. At the heart of quality health care is the trust and integrity of the doctor-patient relationship, and concierge doctors provide this to their patients in abundance. They make themselves available 24 hours a day, seven days a week. Their practice enables them to focus on the unique needs of their patients, rather than playing the numbers game of managed care. But there’s a huge potential for patient manipulation and abuse when large fees and vast sums of personal wealth, power and celebrity enter into the doctor-patient relationship. Concierge doctors and the treatment professionals who work with them must be aware of this potential and take steps to avoid it.

The solution

The solution that addiction professionals should pursue is not insisting that their clients terminate their relationships with their concierge doctors, but rather to minimize their potential for abuse. To accomplish this, addiction professionals who work with an elite client population must recognize that this potential for abuse exists and intervene in a way that dismantles their destructive forces. In my own work, I’m guided by the following five guidelines:

• Thoroughness is key. Gather as much direct and collateral information as you can about your clients. This can be a Herculean task when working with affluent patients and their families, as there are legions of paid professionals supporting the patient’s lifestyle, and addiction. Make a flow chart of the various players and establish a connection to each of them.

• Treat the family as the client. Work holistically. Affluent clients are exceptional at compartmentalizing. Bring as many of the family members as possible into the treatment space. Earn their trust rather than demanding it, then design a treatment plan for the entire family.

• Once you have a clear plan of action that incorporates all the key players in the patient’s life and necessary releases, reach out to the client’s medical team and discuss his/her case though the lens of educating them, rather than accusing them of malfeasance. Expressly ask them to join you in the solution.

• If you believe there is a pattern of abuse, bring it to family members' attention and work collaboratively with them to fashion an intervention.

• Have a process to work through your own discomfort with the task of dismantling deeply entrenched power dynamics. Don’t cave in to the seduction of wealth, power and celebrity. Remember, it’s this seduction that got your client into the trouble they’re in.

While concierge doctors provide a great service to their patients, they also are vulnerable to being manipulated by sophisticated and powerful patients. When these patients suffer from the disease of addiction, the potential for manipulation and abuse increases exponentially. Treatment professionals who work with elite patients must be aware of this dynamic and navigate its terrain with a sophisticated awareness. Success in this regard requires tact, doggedness, compassion and a spirit of inclusion.

Paul Hokemeyer, JD, PhD, is an addictions and family therapist based in Malibu, Calif., and Telluride, Colo. His e-mail address is drpaulnyc@yahoo.com.