TERRY GROSS, HOST:
This is FRESH AIR. I'm Terry Gross. I want to thank Dave Davies for hosting these past few days while I was out with a cold. My guest today is Dr. Anna Lembke, a psychiatrist who treats people who are addicted to prescription drugs including opioids, stimulants like Adderall, sedatives like Xanax and sleeping pills like Ambien. In her new book "Drug Dealer, MD," She writes about the origins of the prescription drug epidemic from a doctor's perspective, including how doctors were encouraged to prescribe pills that ended up being more addictive than they realized and the difficulties that her adolescent teenaged and adult patients have stopping drugs they've become addicted to.
The CDC declared a prescription drug epidemic in 2011 caused by prescription opioid painkillers and psychotherapeutic drugs. Dr. Lembke is an assistant professor at Stanford University and chief of the Stanford Addiction Medicine Dual Diagnosis Center. The dual diagnosis refers to patients who have both a mental health disorder such as depression, bipolar syndrome or schizophrenia as well as a drug or alcohol addiction. Dr. Anna Lembke, welcome to FRESH AIR. You write that when you started practicing psychiatry, you tried not to treat people with addiction problems. Why?
ANNA LEMBKE: In my training in medical school, I was essentially taught that addiction is not an illness. It's a problem that people have to deal with and then come back to me before I can address their other mental health issues. So I didn't treat addiction because I didn't know how to do it and didn't know it was my job to do it.
GROSS: So what changed your mind?
LEMBKE: I was seeing more and more patients coming in who were clearly using substances in a way that was adversely affecting their mental health. And I pretty quickly discovered that if I didn't do something to address their substance use problems, I was never going to make any headway on their bipolar disorder or their schizophrenia, their anxiety, etc.
GROSS: So did most of your patients who were coming in with addiction problems - were they using opioids?
LEMBKE: At first in the early 2000s, I was seeing primarily alcohol, cannabis. I wasn't seeing the kind of prescription drug misuse that I see today. Today, the majority of my practice is people who have become addicted to prescription opioid painkillers, prescription benzodiazepines and prescription stimulants. And it really started to take off in the early 2000s.
GROSS: Why then?
LEMBKE: Well, I think that was, you know, the peak of what we now know to be the prescription drug epidemic, and it all changed along about the 1980s when doctors across the board began prescribing controlled or addictive prescription medicines more prolifically than they ever had before.
GROSS: So what medications do you put in that category?
LEMBKE: In that category are the opioid painkillers, also the benzodiazepine sedatives, things like Xanax and Valium also stimulants like Adderall and Ritalin. Those are the main ones that are in those categories.
GROSS: So most of the patients you were seeing in the late 2000s, the late aughts were patients who got addicted through the use of prescription drugs prescribed by their doctors like legitimately prescribed for them?
LEMBKE: Legitimately prescribed for them, and some of them I was prescribing for them.
GROSS: In what cases would you be prescribed - like what kind of drugs were you prescribing?
LEMBKE: So as a psychiatrist, I wasn't prescribing opioid painkillers, but I was prescribing a lot of benzodiazepines like Klonopin, Xanax and Valium. And I was prescribing a fair amount of stimulants for attention deficit disorder.
GROSS: When did you start realizing that that was actually creating addiction problems?
LEMBKE: Well, it was very insidious and subtle. One of the ways I realized was that my patients weren't getting better. They were asking for more and more medications at higher and higher doses. They were wanting early refills. And then it really wasn't until the prescription drug monitoring program was made available in the state of California where I could go online and see the other prescriptions that my patients were getting from other doctors when I suddenly realized what a huge problem it was not just for patients taking opioid painkillers, but also for my own patients.
For example, I had a patient I was seeing for many years. He was a lawyer, and I prescribed him Ambien 10 milligrams every bedtime. Ambien is a sleep aid and that went on for years. And, incidentally, I decided to check the prescription drug monitoring program and what I found out was that he was seeing at least 10 other doctors who were also prescribing Ambien 10 milligrams daily. He had an Ambien addiction, and I never knew 'til I checked that database.
GROSS: Do you get high on Ambien? I mean, there's only a certain number of hours you can sleep.
LEMBKE: Oh, yeah. No. It's not for sleep. I mean, I think this is a common misconception, you know, that people necessarily take addictive drugs to feel high, you know, kind of a spacey or euphoric way. People who get addicted to drugs can use them for all different kinds of reasons. He was using Ambien primarily to make him feel less anxious, and it also energized him. That's true for many of my patients addicted to prescription painkillers as well, things like Vicodin, Percocet, OxyContin. We typically think of those medications as sedating, but for many people who become addicted, they're very energizing. They kind of give people a kind of a clear-headed awareness a sort of manic energy. They can get a lot done.
GROSS: So when you realize that in a way you were part of the problem, that you were one of 10 doctors, for instance, with this patient who was prescribing Ambien, did you confront your patient?
LEMBKE: Well, confront is usually not the word I would use, but I certainly said to the patient, hey, I think, you know, we have a problem here. I looked at this database, and it looks like, you know, you're going around to different doctors. And it looks like you're addicted, so we need to address that.
GROSS: What was your patient's reaction?
LEMBKE: Well, the reactions are mixed from patients. Some patients start crying. They're relieved and sad at the same time. They're almost always ashamed. Other patients become enraged and storm out. I get hate mail and hate emails and people saying what a horrible doctor I am. Other patients go online and give me poor ratings on sites like Yelp which rate patient satisfaction of doctors, so kind of the full range.
GROSS: You're the chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. What does dual diagnosis mean in this context?
LEMBKE: So dual diagnosis is kind of a coded phrase to identify patients who have mental illness and have a co-occurring addictive disorder. A lot of patients won't want to come to a clinic that headlines as the addiction clinic. So if we call it dual diagnosis, it's sort of a softer, more subtle way of saying this is the clinic where you come to get help with addiction problems. Unfortunately, a lot of people don't know what it means, so I'm not sure how effective it is. And there's always that issue of by continuing to, you know, have code names for addiction, we're just sort of perpetuating the stigma. It might be better if we just get out in the open and call a spade a spade.
GROSS: So you see a lot of people who have become addicted to prescription opioids, right?
LEMBKE: Yes.
GROSS: And you write in your book about how the philosophy of treating pain has changed. Give us a sense of how it's changed.
LEMBKE: Prior to about 100 years ago, doctors believed that pain was salutary, meaning that it had some physiologic benefit to the individual and certainly some spiritual benefit. There was this idea that what doesn't kill you makes you stronger, after darkness comes the dawn. There was also this belief that particularly during some kind of procedure or surgery, the experience of pain could help healing by boosting cardiovascular function and boosting the immune system.
But along about 1850s, that really began to shift, and it began to shift in large part because new medications and remedies to relieve pain were being invented. The bore needle syringe was invented then. So it was a way to deliver opioids more effectively to treat and target pain. And opioids used short term are absolutely fantastic to alleviate pain.
And slowly, what happened over time is that doctors began to feel that pain was something that they had to eliminate at all costs. Today, we think of pain as purely dangerous. We don't see any medicinal value in patients experiencing pain. And certainly, we don't see any beneficial spiritual function for patients experiencing pain.
And it's gotten to the point now where we actually, as a culture - and certainly within medicine - believe that if patients experience pain, it can leave a kind of psychic wound which can increase their risk of future pain. It's very interesting for me as a psychiatrist to look at the parallels between this development with our beliefs around physical pain as well as emotional pain.
So beginning with Freud in the early 1900s, there was this idea that if you have a traumatic experience, that will influence your emotional development as you get older to the point where we came to believe that any kind of psychic trauma could leave a psychic scar and possibly engender a post-traumatic stress disorder.
This idea really then began to be translated toward physical pain to the point where we have come to believe, in the last 30 years, that if patients endure physical pain, then we are putting them at risk for future physical pain through a kind of centralized pain syndrome. And this idea really promoted a lot of opioid overprescribing because patients were fearful to experience pain. And doctors were fearful that if they didn't address pain, this patient might go on to develop some kind of chronic pain syndrome, or even post-traumatic stress disorder, as a result of experiencing pain.
GROSS: But it isn't the fear of chronic pain syndrome related to new neuroscience
suggests
that there are certain, like, pain pathways that are remembered, you
know, after chronic pain and, that way, it could lead to more chronic
pain or could keep the chronic pain going for longer periods of time?
This is FRESH AIR. I'm Terry Gross. I want to thank Dave Davies for hosting these past few days while I was out with a cold. My guest today is Dr. Anna Lembke, a psychiatrist who treats people who are addicted to prescription drugs including opioids, stimulants like Adderall, sedatives like Xanax and sleeping pills like Ambien. In her new book "Drug Dealer, MD," She writes about the origins of the prescription drug epidemic from a doctor's perspective, including how doctors were encouraged to prescribe pills that ended up being more addictive than they realized and the difficulties that her adolescent teenaged and adult patients have stopping drugs they've become addicted to.
The CDC declared a prescription drug epidemic in 2011 caused by prescription opioid painkillers and psychotherapeutic drugs. Dr. Lembke is an assistant professor at Stanford University and chief of the Stanford Addiction Medicine Dual Diagnosis Center. The dual diagnosis refers to patients who have both a mental health disorder such as depression, bipolar syndrome or schizophrenia as well as a drug or alcohol addiction. Dr. Anna Lembke, welcome to FRESH AIR. You write that when you started practicing psychiatry, you tried not to treat people with addiction problems. Why?
ANNA LEMBKE: In my training in medical school, I was essentially taught that addiction is not an illness. It's a problem that people have to deal with and then come back to me before I can address their other mental health issues. So I didn't treat addiction because I didn't know how to do it and didn't know it was my job to do it.
GROSS: So what changed your mind?
LEMBKE: I was seeing more and more patients coming in who were clearly using substances in a way that was adversely affecting their mental health. And I pretty quickly discovered that if I didn't do something to address their substance use problems, I was never going to make any headway on their bipolar disorder or their schizophrenia, their anxiety, etc.
GROSS: So did most of your patients who were coming in with addiction problems - were they using opioids?
LEMBKE: At first in the early 2000s, I was seeing primarily alcohol, cannabis. I wasn't seeing the kind of prescription drug misuse that I see today. Today, the majority of my practice is people who have become addicted to prescription opioid painkillers, prescription benzodiazepines and prescription stimulants. And it really started to take off in the early 2000s.
GROSS: Why then?
LEMBKE: Well, I think that was, you know, the peak of what we now know to be the prescription drug epidemic, and it all changed along about the 1980s when doctors across the board began prescribing controlled or addictive prescription medicines more prolifically than they ever had before.
GROSS: So what medications do you put in that category?
LEMBKE: In that category are the opioid painkillers, also the benzodiazepine sedatives, things like Xanax and Valium also stimulants like Adderall and Ritalin. Those are the main ones that are in those categories.
GROSS: So most of the patients you were seeing in the late 2000s, the late aughts were patients who got addicted through the use of prescription drugs prescribed by their doctors like legitimately prescribed for them?
LEMBKE: Legitimately prescribed for them, and some of them I was prescribing for them.
GROSS: In what cases would you be prescribed - like what kind of drugs were you prescribing?
LEMBKE: So as a psychiatrist, I wasn't prescribing opioid painkillers, but I was prescribing a lot of benzodiazepines like Klonopin, Xanax and Valium. And I was prescribing a fair amount of stimulants for attention deficit disorder.
GROSS: When did you start realizing that that was actually creating addiction problems?
LEMBKE: Well, it was very insidious and subtle. One of the ways I realized was that my patients weren't getting better. They were asking for more and more medications at higher and higher doses. They were wanting early refills. And then it really wasn't until the prescription drug monitoring program was made available in the state of California where I could go online and see the other prescriptions that my patients were getting from other doctors when I suddenly realized what a huge problem it was not just for patients taking opioid painkillers, but also for my own patients.
For example, I had a patient I was seeing for many years. He was a lawyer, and I prescribed him Ambien 10 milligrams every bedtime. Ambien is a sleep aid and that went on for years. And, incidentally, I decided to check the prescription drug monitoring program and what I found out was that he was seeing at least 10 other doctors who were also prescribing Ambien 10 milligrams daily. He had an Ambien addiction, and I never knew 'til I checked that database.
GROSS: Do you get high on Ambien? I mean, there's only a certain number of hours you can sleep.
LEMBKE: Oh, yeah. No. It's not for sleep. I mean, I think this is a common misconception, you know, that people necessarily take addictive drugs to feel high, you know, kind of a spacey or euphoric way. People who get addicted to drugs can use them for all different kinds of reasons. He was using Ambien primarily to make him feel less anxious, and it also energized him. That's true for many of my patients addicted to prescription painkillers as well, things like Vicodin, Percocet, OxyContin. We typically think of those medications as sedating, but for many people who become addicted, they're very energizing. They kind of give people a kind of a clear-headed awareness a sort of manic energy. They can get a lot done.
GROSS: So when you realize that in a way you were part of the problem, that you were one of 10 doctors, for instance, with this patient who was prescribing Ambien, did you confront your patient?
LEMBKE: Well, confront is usually not the word I would use, but I certainly said to the patient, hey, I think, you know, we have a problem here. I looked at this database, and it looks like, you know, you're going around to different doctors. And it looks like you're addicted, so we need to address that.
GROSS: What was your patient's reaction?
LEMBKE: Well, the reactions are mixed from patients. Some patients start crying. They're relieved and sad at the same time. They're almost always ashamed. Other patients become enraged and storm out. I get hate mail and hate emails and people saying what a horrible doctor I am. Other patients go online and give me poor ratings on sites like Yelp which rate patient satisfaction of doctors, so kind of the full range.
GROSS: You're the chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. What does dual diagnosis mean in this context?
LEMBKE: So dual diagnosis is kind of a coded phrase to identify patients who have mental illness and have a co-occurring addictive disorder. A lot of patients won't want to come to a clinic that headlines as the addiction clinic. So if we call it dual diagnosis, it's sort of a softer, more subtle way of saying this is the clinic where you come to get help with addiction problems. Unfortunately, a lot of people don't know what it means, so I'm not sure how effective it is. And there's always that issue of by continuing to, you know, have code names for addiction, we're just sort of perpetuating the stigma. It might be better if we just get out in the open and call a spade a spade.
GROSS: So you see a lot of people who have become addicted to prescription opioids, right?
LEMBKE: Yes.
GROSS: And you write in your book about how the philosophy of treating pain has changed. Give us a sense of how it's changed.
LEMBKE: Prior to about 100 years ago, doctors believed that pain was salutary, meaning that it had some physiologic benefit to the individual and certainly some spiritual benefit. There was this idea that what doesn't kill you makes you stronger, after darkness comes the dawn. There was also this belief that particularly during some kind of procedure or surgery, the experience of pain could help healing by boosting cardiovascular function and boosting the immune system.
But along about 1850s, that really began to shift, and it began to shift in large part because new medications and remedies to relieve pain were being invented. The bore needle syringe was invented then. So it was a way to deliver opioids more effectively to treat and target pain. And opioids used short term are absolutely fantastic to alleviate pain.
And slowly, what happened over time is that doctors began to feel that pain was something that they had to eliminate at all costs. Today, we think of pain as purely dangerous. We don't see any medicinal value in patients experiencing pain. And certainly, we don't see any beneficial spiritual function for patients experiencing pain.
And it's gotten to the point now where we actually, as a culture - and certainly within medicine - believe that if patients experience pain, it can leave a kind of psychic wound which can increase their risk of future pain. It's very interesting for me as a psychiatrist to look at the parallels between this development with our beliefs around physical pain as well as emotional pain.
So beginning with Freud in the early 1900s, there was this idea that if you have a traumatic experience, that will influence your emotional development as you get older to the point where we came to believe that any kind of psychic trauma could leave a psychic scar and possibly engender a post-traumatic stress disorder.
This idea really then began to be translated toward physical pain to the point where we have come to believe, in the last 30 years, that if patients endure physical pain, then we are putting them at risk for future physical pain through a kind of centralized pain syndrome. And this idea really promoted a lot of opioid overprescribing because patients were fearful to experience pain. And doctors were fearful that if they didn't address pain, this patient might go on to develop some kind of chronic pain syndrome, or even post-traumatic stress disorder, as a result of experiencing pain.
GROSS: But it isn't the fear of chronic pain syndrome related to new neuroscience
LEMBKE: This is certainly the neuroscience. But really, I think it's important to acknowledge that this is very much a social construct, even more powerfully than it's neuroscience, because the truth is we don't have any idea what's going on in the brain. And we don't understand why otherwise healthy people are coming to our offices now complaining of corpodynia (ph) - corpa meaning body and dynia meaning pain. And there's no biological reason that we can find for them to experience this pain.
So yes, the pain is in the brain. It's some kind of centralized pain process. But I think it's really important to acknowledge that this is also something that, culturally and socially as a narrative, we've now handed people as a way to express their suffering without really fully understanding what is going on biologically.
GROSS: So as we said, a lot of your patients are addicted to opioids. And they became addicted after being prescribed opioids for pain. Do you - have you reached a conclusion, personally, for how long you think it's safe for somebody to take an opioid for pain without risking addiction?
LEMBKE: I don't think it's possible to come up with a definitive amount of time because people are so different. Some people can truly take opioids for months at a time and never get addicted, and other people will be addicted almost instantly. And the reason for those differences are not well understood but probably have something to do with underlying genetic vulnerability, prior exposure to opioids, their psychosocial circumstance, their socioeconomic circumstance. But in general, my philosophy is to use opioids to treat pain as sparingly as possible and to really think of them as an effective treatment for acute pain but not a long-term strategy.
GROSS: So, for instance, when you come out of surgery and you're going to be in severe pain for a couple of days or so.
LEMBKE: That's right. So right after an acute trauma, right after surgery - and also at the very end of life when it's clear that the individual has maybe only days or weeks to live. I think that that's an empathic and compassionate intervention that I wouldn't want to deny anybody. But what happens when people continue to use opioids long term - even if they started the opioids for an acute intervention - is that the body responds by very quickly adapting to the presence of that chemical, such that it really stops working.
A lot of my patients will say to me - but I still feel like it works; when I take that second dose, I can feel my pain going away. And what I say to them - I said, well, that's possible. But it's also possible that you're just medicating the withdrawal from your last dose. The other thing that happens with long-term opioid use is that it can cause something called opioid-induced hyperalgesia, where it changes the pain threshold so that individuals actually experience more pain over time.
Just yesterday, I saw a couple of patients in my clinic, both of whom were on high-dose opioids for low back pain for about 15 years. About six months ago, we got them both off of opioids. And amazingly, they both report their pain is virtually gone. So this is really remarkable and, I think, worth, you know, taking a moment to observe. These were individuals on high-dose opioids for years - in terrible pain despite those medications. Now off of opioids - sixth month and pain is completely resolved.
That's not going to be true for everybody who gets off opioids, but it's true enough of the time that I'm a believer.
GROSS: If you're just joining us, my guest is Dr. Anna Lemke. She's the author of the new book "Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, And Why It's So Hard To Stop." She's also the chief of the Stanford Addiction Medicine Dual Diagnosis Clinic where she treats patients who have become addicted to prescription drugs. We'll be back after we take a short break. This is FRESH AIR.
(SOUNDBITE OF ANDREW BIRD SONG, "I")
GROSS: This is FRESH AIR. And if you're just joining us, my guest is Dr. Anna Lembke. She's chief of the Stanford University Addiction Medicine Dual Diagnosis Clinic, where she treats patients who have become addicted to prescription drugs, including opioids. And she's the author of the new book "Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, And Why It's So Hard To Stop."
Now we've been talking a lot about opioids. But you also deal with addiction to, for instance, Adderall, which is often prescribed for attention deficit disorder. And you say this is a drug that has a high potential for misuse and addiction. Describe for us why it's prescribed for ADD.
LEMBKE: Well, medications like Ritalin and Adderall are stimulants, but they're biochemically essentially the same as street methamphetamine. And they're prescribed to enhance cognitive function in individuals who are thought to have cognitive function disorders like attention deficit disorder. And they're often prescribed in childhood at ever younger ages.
I have heard of patients as young as two years of age getting stimulants for purported attention deficit disorder, and I would say in particular the generation of the millennials is a generation that has experienced intense prescribing of stimulants for attention deficit disorder.
GROSS: Are children and teenagers especially vulnerable to addiction?
LEMBKE: So adolescence is a time of neuronal pruning. And what that means is that at about age 6, we have more neurons than we'll ever have in our lives. It's a very arborized branching tree.
And as we enter early adolescence, the number of neurons that we have begins to scale back and be pruned just like pruning a tree because the accessory neurons that we don't use, we can get rid of, so that we're just left with those neurons that we absolutely need, and adolescence is this time of scaling back or pruning. And the concern because the brain is developing at such a crucial moment in adolescence, the concern is that if young people are using addictive substances during that crucial period of neuronal pruning that they will essentially create a scaffolding that depends on that drugs such that later it will be very difficult to remove that drug and have them be functional.
So, yes, we do know that the earlier an individual starts using an addictive drug, the more likely they are to go on and become addicted. And the grave concern from the neuro scientific point of view is that this very vulnerable period of neuronal development is compromised when that young person is using drugs heavily.
GROSS: So have you seen a lot of people who became addicted to drugs like Ritalin or Adderall as adolescents and are having a hard time giving up those drugs?
LEMBKE: I do see that often in my practice, so there's a - I know there is a large cohort of people who take stimulants for attention deficit disorder and never get addicted and can stop at any point. But I do see those individuals who do become addicted very quickly over the course of time in adolescence and young adulthood and then find it very, very difficult to stop using those substances.
GROSS: And you write that you see a fair number of patients who, you know, as teenagers have been or are taking something like Adderall or Ritalin to focus their attention and help them start the day. And then they're taking something, you know, to help them sleep at night. Is that of special concern to you when you see a kind of, you know - like more than one medication like that that's potentially addictive?
LEMBKE: I see a lot of patients who are on an opioid for pain, a benzodiazepine like Xanax to help them sleep, a stimulant in the morning to get them going. They might use a little bit of cannabis here and there to help them with their anxiety. And, yes, it is of grave concern to me. Something that I always look for is the holy trinity - an opioid, a benzo and a stimulant - because basically those medications are working at cross purposes, right? If you're taking a stimulant in the morning to get yourself going, but then you're using a sedative later in the day to put yourself to sleep, you're creating a kind of a vicious cycle.
And oftentimes, those medications are prescribed by individual different prescribers, each of whom may not know what the other is prescribing. And this is, again, a big part of what's driving the epidemic is the sort of disjointed health care system that we have now where the right hand doesn't know what the left hand is prescribing.
GROSS: My guest is Dr. Anna Lembke, a psychiatrist who's chief of the Stanford Addiction Medicine Dual Diagnosis Center where she treats patients who are addicted to drugs and also have a mental health disorder. Her new book is called "Drug Dealer, MD." We'll talk more about the origins of the prescription drug epidemic after we take a short break. I'm Terry Gross, and this is FRESH AIR.
(SOUNDBITE OF MUSIC)
GROSS: This is FRESH AIR. I'm Terry Gross, back with Dr. Anna Lembke, the author of the new book "Drug Dealer, MD," which gives a doctor's perspective on the prescription drug epidemic. She's a psychiatrist on the faculty of Stanford University and chief of the Stanford Addiction Medicine Dual Diagnosis Center, where she treats people who are addicted to opioids, sedatives, stimulants and psychotherapeutic drugs and also have a mental health disorder, including depression, bipolar disorder and schizophrenia.
Have what doctors been told about the use of opioids changed over the years?
LEMBKE: Starting in the 1980s, doctors started to be told that opioids were effective treatment for chronic pain and that treating patients long term with opioids was evidence-based medicine. That was patently false, and that was propagated by what I call big medicine in cahoots with big pharma.
The other myth about long-term opioids that doctors were taught was that no dose was too high. So if you had a patient who responded to opioids but then developed tolerance where that dose wasn't working, when they came back in, you should just give them more opioids. And that's how we got to this place where we have patients who are on unbelievable doses, just astronomical amounts.
The third myth about opioids that doctors were told was that opioids are not addictive as long as you're prescribing them for a patient in pain, as if there was some sort of magic halo effect with a prescription. And that also is obviously not true. Now we're seeing studies showing that upwards of 50 percent of patients taking opioids long term for a medical condition begin to show signs and symptoms of addiction to those opioids.
GROSS: You said that part of the opioid problem was that big medicine and big pharma were in cahoots in contributing to this. That's a big statement. What do you mean by that?
LEMBKE: Yeah. So the pharmaceutical industry realized that they can no longer directly go to doctors to get them to prescribe their pills. That was - there - various regulations were put in place to prevent them giving gifts and pens and hats and things that we do know can influence doctor prescribing. So instead, they took a kind of Trojan horse approach and infiltrated the regulatory agencies and academic medicine in order to convince doctors that prescribing more opioids was evidence-based medicine.
And evidence-based medicine means medicine that's based on science, and that's something that - all doctors are supposed to practice evidence-based medicine. So, for example, what they did was Purdue Pharma joined forces with The Joint Commission, and The Joint Commission is an organization that accredits hospitals. And Purdue Pharma gave all kinds of teaching material to The Joint Commission and said you really need to make, you know, doctors treat pain more aggressively, and that needs to be a quality measure.
So The Joint Commission said - you know what? - you're absolutely right, and we're going to do that. And we're going to take your videos that you made that tell doctors that opioids aren't addictive as long as they're treating them for pain, and we're going to create this visual analog scale of little happy faces and sad faces and this numerical scale. And we're going to make doctors go in there...
GROSS: Where you rate your pain 1 to 10.
LEMBKE: Right, where you rate your pain 1 to 10. And we're going to tell doctors that they have to start going and asking every single patient, rate your pain from 1 to 10. And if they don't do that, then they're not being good doctors. And so what happened was that doctors felt tremendous pressure over the last two decades to not only ask patients about their pain and have them rate their pain on this scale from 1 to 10 with the little smiley faces of the visual analog scale but also aggressively treat that pain and eradicate it because when the patient was discharged, the patient was then asked - did your doctor do everything in her power to eradicate your pain?
And, you know, if the patient said no, they didn't on that survey, then it looked really bad for the doctor. It looked bad for the hospital, and it meant that they would get dinged on The Joint Commission survey. So it became a kind of groupthink where it looked like treating pain aggressively with opioids was something that was based on science when, in fact, it was based on big pharma's influence of these major regulatory bodies.
GROSS: Were you directly affected by that in any way? Did you see that in action?
LEMBKE: I really did. I would be consulted on these cases in the hospital of patients on astronomical doses of opioids, admitted for low back pain, who were clearly addicted. You did not need a medical degree to diagnose an opioid addiction in these individuals because in addition to prescription drugs, they were using heroin, and they freely admitted it.
So I would go in, and I would say, you know, what's the consult question? They would say - is the patient addicted to opioids? And I would review the history and talk to the patient. And I would say to the consulting team - well, the patient is obviously addicted to opioids. And did you really need me to say that? You know, I mean, I really - I mean, I - I think it's so patently obvious. And they would say, well, thank you, Dr. Lembke. And they would sort of send me on my way.
And then I would find out later that not only was - were my recommendations not followed - my recommendations being to taper the patient down and off of prescription opioids and refer her for addiction treatment - but that the doctors just kept on prescribing at those high doses and discharged the patient with a great big bottle of pills. And a month later, they would come back with the same problem, wanting more opioids because they ran out of their supply.
And that was so mind-boggling to me and really is what inspired me to want to write this book - why is this happening? Because I know these doctors, and they're good people. They're caring people. They're good doctors. Why are they doing this crazy stuff?
And what my book really tries to get at is to understand all of those complex forces, including the incredible pressure on doctors at that time to aggressively eradicate pain in every single patient, as well as the wholesale - really, neglect of addiction within the house of medicine. We don't have infrastructure to treat addiction. Doctors aren't trained in the management of identifying or treating addiction. And so we're left with this kind of crazy phenomenon where even obviously addicted patients don't get recognized because there's no path for them.
GROSS: So has that pressure - that you've described - on doctors to prescribe pain medication for their patients, has that changed?
LEMBKE: It's definitely changed. And it really shows what a blunt instrument, you know, the change in medicine is because, now, we have almost, in many cases, the opposite problem. Now we have patients who have been on opioids long term, who are certainly physiologically dependent, if not if not addicted, who are now - can't get opioids.
So one term used to describe these people is opioid refugees. They're sort of going around from clinic to clinic, and they can't get anybody to prescribe opioids for them. And it's very tragic because some of these patients really do have very serious pain conditions. They're in terrible pain. And their opioids may, in some cases, be helping them.
But even if the opioids are still not the best path for them, we can't just abandon those patients. We have to help them slowly get off of their opioid. That's not something you can do in a day, particularly if you've been taking them for decades.
GROSS: If you're just joining us, my guest is Dr. Anna Lembke. She's the author of the new book "Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, And Why It's So Hard To Stop." She is also the chief of the Stanford Addiction Medicine Dual Diagnosis Clinic, where she treats patients who have become addicted to drugs and also have a mental health problem.
We're going to take a short break, then we'll be right back. This is FRESH AIR.
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GROSS: This is FRESH AIR. And if you're just joining us, my guest is Dr. Anna Lembke. She's chief of the Stanford Addiction Medicine Dual Diagnosis Clinic where she treats patients who have become addicted to drugs and who also have a mental health problem. She's the author of the new book "Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, And Why It's So Hard To Stop."
I assume that when patients come to you, they come to you because they already know they have some kind of addiction problem 'cause that's what you specialize in. Nevertheless, do you sometimes have to really work hard to convince your patients that they have to give up the drug - or drugs?
LEMBKE: I have to work very hard to convince my patients because even though my clinic is the Addiction Medicine Dual Diagnosis Clinic, a lot of patients get referred to my clinic when they didn't really necessarily want help with substance use. They want help with anxiety. They want help with depression. And then based on, kind of, the screening history that our intake coordinators do, it's discovered that they probably have a substance use problem, then they end up in my clinic.
And then, yes, I am in the position of trying to persuade that individual that we need to target their substance use at the same time that we're trying to target their anxiety or their depression or their chronic pain. And basically, what I tell patients is - I probably can't help you with your depression and your anxiety while you're continuing to use substances at the level that you're using them.
The data show that your mental health issues won't get better as long as you're actively using addictive substances. My clinical experience tells me that you're not going to get better unless we target both at the same time. I have to do a lot of validating with patients that I'm not ignoring their addiction and anxiety but letting them know that, from a pragmatic point of view, we're probably not going to make any progress unless we also address their substance use.
GROSS: As a doctor, you want to be, you know, to show empathy for your patients. And you're telling them things they don't want to hear.
LEMBKE: That is very true, and that's really challenging. And I have - I think I'm getting better at the art of saying no nicely. But it's not something that we really learn in medical school, and it's something that I think most doctors have a hard time with because we go into medicine because we like helping people. And we want to experience the warm fuzzies of, you know, having helped somebody and them expressing gratitude.
And so to be in conflict with our patients around what their goal is and what my goal is for them is extremely challenging, and it's something that a lot of doctors avoid, which is also why a lot of doctors don't even ask their patients about substance use problems - because they just don't want to go there. They don't want to have to deal with the tension that arises in the interaction in the moment when they are talking about something that the patient is resistant to talking about.
But I feel like that is my job to do that. And I feel like I've developed skills over time. And I certainly - I spend a lot of time teaching residents and training - and other physicians, you know, how can I remain in a compassionate stance and express empathy and really mean it while also telling this patient, you need to change your behavior?
GROSS: Well, you mention in your book that you had one patient who you felt was addicted to pain medication. But that patient threatened to sue you if you didn't prescribe more pain meds. So what do you do in a situation like that?
LEMBKE: So that is, fortunately, happening less than it was now that the tide has changed a little bit around the pressure on doctors to prescribe opioids and eradicate pain at all costs. But nonetheless, I get a version of that quite often. And frankly, you just have to develop thick skin and not become reactive. What helps me remain in a compassionate stance vis-a-vis patients like this is I really try to understand their behavior as part of their pathology, part of their addiction and just be able to communicate to them that I care about them even though I'm not saying what they want to hear.
And I think - I do believe that when you authentically do want what's best for patients, they can feel that on some level. And they might not, you know, want to acknowledge it in the moment. But a lot of times patients will go away angry and then come back later and actually, you know, want help.
GROSS: Have you ever been in a situation yourself where you are in, you know, great pain either because of surgery or an injury and you had to decide whether you wanted to accept a prescription for an opioid?
LEMBKE: I've never been in that situation.
GROSS: Have you asked yourself what you would do if you were?
LEMBKE: I have asked myself that, and I've had patients ask me that. And I've had angry people who are angry - in fact, there's a - one person who reviewed my book on Amazon said that he wished for me that I could undergo major surgery without any pain relief at all so that I would understand what I was talking about.
So yeah, I mean, I - you know, people get angry when I talk about, you know, this topic because there are people out there who are enduring unbelievable pain, and I have tremendous empathy for them. But I still firmly believe that most of those people would be better off off of opioids or on a much lower dose or only using opioids intermittently.
And as for, you know, my own fortitude in the face of physical suffering, I wouldn't even presume to guess how I would react. You know, I don't think we really know how we will respond in the face of emotional or physical suffering till we get there, and then we find out.
GROSS: Since you're only seeing the patients who are addicted, and you're not the seeing patients for whom opioids or Adderall or Ritalin or, you know, Klonopin or whatever worked really effectively, do you think that you're biased because you're only seeing the people who have had problems and you're not seeing the people who have benefited without problem?
LEMBKE: I'm totally biased.
GROSS: OK.
(LAUGHTER)
LEMBKE: I mean, there's no doubt about it.
GROSS: So how do we take that (laughter)?
LEMBKE: Well, you know, what I'm trying to highlight here is that - not that these medications are bad in all circumstances. What I'm trying to highlight is that the risk is tremendous and that we have really not, heretofore, appreciated the extent of the risk and that most doctors are completely clueless about the addictive nature of medications that they're prescribing, and they don't tell their patients about the addictive potential so patients don't know.
And so I'm trying to raise awareness around the dangers inherent in overprescribing these medications which is not the same thing as saying they have no utility or they should never be prescribed or no one anywhere on planet Earth should ever take opiates chronically. I don't believe that. I believe that there are patients out there who take opioids every day for some kind of chronic pain condition for whom it is incredibly helpful and life-changing. I believe it 100 percent. But I think those patients are the minority. I think the majority of people on chronic opioid therapy will develop problems that make the drug riskier than it is helpful.
GROSS: Dr. Anna Lembke, thank you so much for talking with us.
LEMBKE: Oh, it was my pleasure. Thank you, Terry.
GROSS: Dr. Anna Lembke is the author of the new book "Drug Dealer, MD." She teaches at Stanford University and is chief of the Stanford Addiction Dual Diagnosis Clinic. This is FRESH AIR.
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'Drug Dealer, M.D.': Misunderstandings And Good Intentions Fueled Opioid Epidemic
"Doctors believed that pain was salutary," she tells Fresh Air's Terry Gross, "meaning that it had some physiologic benefit to the individual, and certainly some spiritual benefit."
But as prescription painkillers became more available, patients became less willing to endure pain. Suddenly, Lembke says, "doctors began to feel that pain was something they had to eliminate at all cost."
Prescriptions for opioid painkillers increased, and so, too, did cases of opioid addiction. In 2011, the Centers for Disease Control and Prevention declared a prescription drug epidemic as a result of doctors overprescribing painkillers to patients. Lembke's new book, Drug Dealer, MD, explores the origins of the prescription drug epidemic from a doctor's perspective.
"Starting in the 1980s, doctors started to be told that opioids were effective treatment for chronic pain, and that treating patients long-term with opioids was evidence-based medicine," she says. "That was patently false and that was propagated by what I call 'big medicine,' in cahoots with Big Pharma."
Interview Highlights
On how Lembke realized there was a problem in her own practice
Drug Dealer, MD
How Doctors Were Duped, Patients Got Hooked, and Why It's So Hard to StopFor example, I had a patient I was seeing for many years, he was a lawyer and I prescribed him Ambien, 10 milligrams every bedtime. Ambien is a sleep aid. And that went on for years, and, incidentally, I decided to check the prescription drug monitoring program and what I found out was that he was seeing at least 10 other doctors who were also prescribing Ambien, 10 milligrams daily. He had an Ambien addiction, and I never knew until I checked that database.
On treating patients with perplexing pain
I see a lot of patients with mysterious chronic pain syndromes, and many of them are young people who otherwise have no evidence of disease, but are completely debilitated and nonfunctional by their mysterious chronic pain syndromes. ...
What ends up happening to these patients often is they get "medicalized," and by that I mean they end up seeing four or five or 10 different specialists. Everybody has a different diagnosis. They get poked and prodded and "surgerized," and by the end of it they come out five or 10 years later with real bona fide physical problems because they've had so many surgeries and so many interventions. And by then they're also on very high-dose opiates.
On how what doctors were told about opioids changed over the years
Doctors were taught that no dose was too high. So if you had a patient who responded to opioids, but then developed tolerance where that dose wasn't working, when they came back in you should just give them more opioids. And that's how we got to this place where we have patients who are on unbelievable doses, astronomical amounts. ...
Doctors were told that opioids are not addictive as long as you're prescribing them for a patient in pain, as if there was some sort of magic halo effect with the prescription. That also is obviously not true. Now we're seeing studies showing that upwards of 50 percent of patients taking opioids long-term for a medical condition begin to show signs and symptoms of addiction to those opioids.
On what Lembke means when she says that big medicine and Big Pharma "were in cahoots"
The pharmaceutical industry realized that they can no longer directly go to doctors to get them to prescribe their pills. Various regulations were put in place to prevent them giving gifts and pens and hats and things that we do know can influence doctor prescribing. So instead they took a kind of Trojan horse approach and infiltrated regulatory agencies and academic medicine in order to convince doctors that prescribing more opioids was evidence-based medicine, and evidence-based medicine means medicine based on science, and that's something that all doctors are supposed to practice. ...
So for example, what they did was Purdue Pharma joined forces with the Joint Commission, and the Joint Commission is an organization that accredits hospitals, and Purdue Pharma gave all kinds of teaching material to the Joint Commission and said, "You really need to make doctors treat pain more aggressively and that needs to be a quality measure." So the Joint Commission said, "You know what? You're absolutely right, and we're going to do that and we're going to take your videos that you made that tell doctors that opioids aren't addictive as long as they're treating them for pain." ...
So it became a kind of groupthink where it looked like treating pain aggressively with opioids was something that was based on science, when in fact it was based on Big Pharma's influence of these major regulatory bodies.
Dr. Anna Lembke is a psychiatrist who treats people who
are addicted to prescription drugs, including opioids, stimulants,
sedatives and sleeping pills.
It's not something that we really learn in medical school, and I think it's something most doctors have a hard time with, because we go into medicine because we like helping people and we want to experience the warm fuzzies of having helped somebody and them expressing gratitude. And so to be in conflict with our patients around what their goal is and what my goal is for them is extremely challenging. ...
It's something that a lot of doctors avoid, which is also why a lot of doctors don't even ask their patients about substance abuse problems, because they just don't want to go there. They don't want to have to deal with the tension that arises in the interaction, in the moment when they are talking about something that the patient is resistant to talking about. But I feel like that is my job to do that, and I feel like I've developed skills over time.
Source: http://www.npr.org/sections/health-shots/2016/12/15/505710073/drug-dealer-md-contends-that-well-meaning-docs-drove-the-opioid-epidemic
Anna Lembke
Associate Professor of Psychiatry and Behavioral Sciences (General Psychiatry and Psychology-Adult) and, by courtesy, of Anesthesiology, Perioperative and Pain Medicine at the Stanford University Medical Center
Dr. Anna Lembke received her undergraduate degree in Humanities from Yale University and her medical degree from Stanford University. She is on the faculty of the Stanford University School of Medicine, a diplomate of the American Board of Psychiatry and Neurology, and a diplomate of the American Board of Addiction Medicine. She is the Program Director for the Stanford University Addiction Medicine Fellowship, and Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. She has published over 50 peer-reviewed articles, chapters, and commentaries, including in the New England Journal of Medicine, the Journal of the American Medical Association, the Journal of General Internal Medicine, and Addiction. Dr. Lembke sees patients, teaches, and does research. She is the author of a book on the prescription drug epidemic: “Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop” (Johns Hopkins University Press, October 2016).
Dr. Anna Lembke's key areas of interest include treating patients who have become addicted to prescription drugs. She takes a holistic, harm-reduction approach to each patient, and encourages spiritual and alternative therapies in the process of healing.
Clinical Focus
- Co-occurring addiction
- Addiction Medicine
