November 17, 2019
The Opioid Epidemic: From Freud to Fentanyl with Anna Lembke

The Opioid Epidemic: From Freud to Fentanyl with Anna Lembke

So I’m excited to be here today to
talk to you about the opioid epidemic the subtitle from Freud to Fentanyl. I will become clear in
the course of the lecture. I have been retained as a medical
expert witness in federal and state opioid litigation over
my opinions are my own. My book was published before I was
retained as a medical expert witness and it goes without saying that I was not
paid for the content in this talk today. So this is the material
that I’m gonna be covering. Basically, I wanna talk about the way
that opioid prescribing has changed from the 1990’s till today. I wanna talk about the invisible
forces inside and outside of medicine that are driving opioid prescribing and
then, finally, what we can do about it. A shorter way to say the same thing is
I’m gonna talk about what happened, why did it happen, and how we can fix it. So first of all, what happened? Prior to 1980 doctors were reluctant to
prescribe opioids because they were afraid their patients would get addicted to them. And for good reason, this country
had seen two prior opioid epidemics, one that started with
soldiers using morphine during the Civil War that culminated
in the narcomania of the early 1900s. When heroin was sold next to Bayer aspirin
as a cough and cold remedy for babies. By the way, heroin is just morphine
with to a pseudo groups at it was supposed to be the non
addictive alternative to morphine. Remember that theme it will recur. Then in the Vietnam era, we saw another
major opioid epidemic in this country when our vets were coming
home addicted to opium. One very interesting thing about
that that also is a resonating theme is that when they came back, more than two thirds of them had
a resolution of their opiate addiction simply by being back in the United States
where they had decreased access. And then we have our current opioid
epidemic, which in terms of scale and impact, in terms of mortality
is unrivaled in terms of any other drug epidemic in this country. Basically, what happened in
the 1980s in medicine is that doctors recognized that we were not
doing enough to help patients with pain. The 1980s was also the advent of
the Hospice movement imported from Europe when there was recognition that
people were dying in extremese. There was the idea that hey, let’s use
opioids more liberally to help people in extreme pain and
to help people at the very end of life. In other words, what started out as
a very well intentioned movement inside medicine ultimately gave way to
doctors dispensing opioids like vending machines to pretty much anybody who walked
in the office and said, I have pain. In other words,
there was a quinine paradigm shift inside of medicine where opioids
became first line treatment for minor pain conditions and
also chronic pain conditions. They basically became the default
to treat pain, period. And it’s no coincidence
that this epidemic is in sync exactly with an increase
in opioid prescribing. So opioid prescribing in this country
quadrupled between the 1990s and about 2010, it peaked in 2012 and
along with that we saw a quadrupling in opioid overdose
mortality in this country. That is not a coincidence, that is causal. This is a picture that was taken
by the Ohio police Department. How many people in this audience
have seen this picture before? Okay, so quite a few of you. Are these individuals pulled over on the
side of the road in their minivan in Ohio. The two individuals in
the front are not deceased, they’re unconscious as a result of
opioid and their opioid addiction. The woman in the front is the grandmother
of the child in the back and this is her friend. Note the watchful waiting of
the child in the background which really speaks to
the multigenerational trauma of addiction. So who’s prescribing all of these pills? We will read a lot about so
called pill mill doctors. These are doctors who are willfully
exchanging prescriptions for cash. These are doctors who have
lost their moral compass. Certainly, those kinds of doctors exists,
they have always existed. But if you think that pill mill
doctors are the primary driver of this epidemic thing you
have misunderstood it. This epidemic is not the result of
a small subset of prolific prescribers. We are all prescribing too many opioids. This is a study that we published in JAMA,
when we looked at the medicare database from 2013
to see who’s prescribing opioids. And really the most important take home
message from our study was that, again, it’s not a small subset of
prolific prescribers driving this, that everybody in medicine is prescribing too many opioids no matter
what your medical specialty. If you look at it by volume, it’s internal
medicine and family medicine doctors as well as nurse practitioners
because there are more of them. If you look at it by specialty,
it’s pain doctors, which makes sense. But really the bottom line is that
everybody in medicine today prescribes too many opioids for minor and
chronic pain conditions. This is from the National Survey
of drug use and health. The take home message from this image is
that great big yellow circle is the more than 11 million people in this country
who misuse prescription opioids, okay? So we’re not talking about heroin,
we’re not talking about illicit fentanyl, we’re talking about more than 11
million people in this country who are developing some kind of
opioid use disorder or addiction. Now compare that to this much smaller
circle, which is the approximately a million people who use heroin,
also a huge problem. But again, I just wanna make sure that you
leave today understanding that heroin is huge problem in this country,
illegal fentanyl the huge problem. But prescription opioids
are the origins of this epidemic and continue to be a very significant problem. Where are people getting the prescription
opioids that they are misusing? Well, what you will see here is that about
35% get them from a single prescriber. The large section here is those
who get them from a friend or family member, many of whom got
them from a single prescriber. What this gets at is that whether it
directly or indirectly, prescribers are the major conduit of misused
prescription drugs in this country. This also importantly speaks to something
that I’ve called the tsunami effect. Part of what has driven
this opioid epidemic is not just people getting addicted through
their doctor’s prescriptions, but the huge increase in pills in
medicine cabinets across the country that teenagers and
other people also have access to. Okay, so that gives you kind of broad
brush strokes of what happened. Where are we now in terms of this
opioid overprescribing problem? Well, opioid prescribing peaked
in about 2011, 2012, and has decreased approximately
30% since that time. So that is the good news,
but here’s the bad news. There is still huge geographic variability
in opioid prescribing in this country and we’re gonna get into a little bit
what may be driving that, but just take a look at some of these data. In 2012 in the United States,
doctors were writing on average, 81 opioid prescriptions per
100 persons in this country. In 2017 which is the last year for which
we have reliable data that went down, that’s the good news to 59 opioid
prescriptions per 100 persons. But look at the state of Alabama in 2017,
107 opioid prescriptions Per 100 persons a decrease from
121 opioid prescriptions that were being read in Alabama in 2012 but still
you can see we’ve got a long way to go. Some counties have rates that
are seven times the national average. This is a heat map the darker
red is more opioid prescribing, the lighter is less opioid prescribing. This is when we peaked at 2012
watch what happens over time, keep your eye on Alabama and
the Southeastern United States. 2017 we’ve made a lot of progress but
we’re still not where we need to be. Also look at this same heat map
when you divide it by county, you’ll note that even in states where
opioid prescribing is relatively low, there are counties where there’s
a lot of opioid prescribing going on. And if you compare how we’re prescribing
today compared to the rest of the world, we’re still prescribing three
to four times as many opioids as most other developed countries. More than 10 times as many opioids as
Japan and here’s an interesting thing. Germany and Canada just switched places, Canada was in second place,
now Germany has moved up. One thing we know that’s happening is that
Mundipharma, an outreach of Purdue Pharma has now taken its marketing
campaign to countries abroad. Also at the same time that opioid
prescribing has been going down, it appears as if benzodiazepines
prescribing Valium, Xanax, Klonopin is going
up in this country. Along with associated
deaths when opioids and benzos are co prescribed,
the risk of accidental overdose goes up. How do people die from opioids? Well, basically, they fall asleep,
they stop breathing and they don’t wake up again because
opioids slow down the heart rate, they slow down the respiratory drive. When you add Xanax or Valium to
an opioid that increases the risk of that kind of sedation and
accidental overdose. This is just one of many typical examples
of cases that I have seen in my career and you’ll note this one was in 2017. This was a 28 year old male,
he had a diagnosis of chronic pain. There was no know disease or
tissue damage to explain his pain but unless he had pain from the top of
his head to the tip of his toes. And he was on the following regimen
prescribe to him by his very reportedly very nice and I believe it well
educated primary care doctor. 40 milligrams of Opana and
opioid twice a day. 30 milligrams of Dilaudid and
opioid once a day. 60 milligrams of Oxycodone and
opioid once a day. 20 milligrams of Valium
benzodiazepines once a day. 65 milligrams of Phenobarb a sedative. 30 milligrams of Temazepam once a day and no list would be complete without
8 milligrams of Xanax once a day. So this young man with no known disease
ideology other than the endorsement of having severe chronic pain,
which I believe he has, is at imminent risk for
overdose death with this regimen. Just to kind of put that in perspective, he’s on 470 morphine
milligram equivalents daily. The average heroine addicted person
takes about approximately a 100 morphine milligram equivalents daily. So, all these prescribed by a doctor,
a good doctor, a well educated doctor and sanctioned by our modern
healthcare system. Now we’re in what’s being called the
second and the third waves of the epidemic what you’ll see here is that
approximately around 2013 or so, there was a spike in heroin
related overdose deaths. By the way, you’ll note here, this is
prescription opioid related deaths, which has plateaued,
I mean maybe even gone down slightly but it still pretty darn high, right? And then you have this spike in heroin and
then right here synthetic opioids, especially fentanyl which we know is 50
to 100 times more potent then heroin is. So what happened? How do we understand this? Basically, the first way to understand
this is the gateway effect. That essentially, Vicodin,
Oxycodone, Percocet, got folks addicted and
the natural progression of addiction is that people look for
more and more potent sources and cheaper sources, price point really
matters when people become addicted. And so they’ve gone prescription opioids to elicit sources as those became
cheaper and more available. Also, partially explaining this
is the fact that as we have pulled back on opioid prescribing
individuals can now no longer get the opioids that they used
to get from their doctor. Some of those individuals are now
going to the illicit market. And then of course very
importantly tsunami effect, right? Just the fact that all of those pills
are in all of those medicine cabinets means that for some vulnerable teenagers, they just really have to get one
prescription and try it once. And then, they’re off and
running to illicit sources. So unfortunately, what we’re seeing is
that doctors fearful of repercussions for opioid prescribing in
the context of this epidemic are now no longer being willing
to treat some patients with pain. This was a study that was done where there
was a confederate who pretended to be the child of an older person with pain, who called a Michigan
primary care clinic and said. Will you treat my father or
my mother they’re on this opioid regiment. 40% of primary care clinics in Michigan
said we’re not gonna treat your parent, we won’t even see them as a patient. So, this is part of the repercussion,
it’s gotten so bad as you can see here, this is just another example. The fact that many high school students
who get addicted to prescription opioids started with a prescription
from their doctor and here’s an interesting statistic. In the 1960s, 80% of heroin users started
with heroin, today, if you interview heroin users 75% of them will tell you
that they started with a prescription opioid again, a very different
phenomenology in terms of this epidemic. Okay, so what I wanna do next is delve a little
bit more deeply into how this happened. And what I really I’m gonna end up trying
to convince you of is that the current opioid epidemic is in fact,
the canary in the coal mine for our faltering healthcare system. That in fact opioids became the solution
not to patients problems but to doctors problems. In order to really understand
how that came about, I think its important to understand what drives
and motivates the compassionate doctor. Because at the end of the day, it’s not
the pill mill doctor who has lost their moral compass but the compassionate
doctor, behind this opioid epidemic. So what motivates
the compassionate doctor? Well, first and foremost, people that
go into medicine tend to be pleasers, they tend to be people who
want to help other people. I would even argue that they’re
kind of natural codependents->>[LAUGH]>>Not just speaking for myself, but myself included. They’re also people who are really
good at figuring out complex systems, including the school system,
to get to the top of their class, to get into medical school
in the first place. They’re also people who are responding
to a higher calling, right? They go into medicine because they want
to save lives and alleviate suffering, this becomes a primary motivator for
them in their practice. As they as we go through medical practice
we’re we’re very heavily socialized To put ourselves in our patients’ shoes,
to imagine their suffering. We get very little training on what to do
if our patients may be manipulating or deceiving us. And in the 1990s, in addition to there being this paradigm
shift in the treatment of pain, this was also the beginning of what was called
the evidence based movement in medicine. This idea that we would eliminate quackery
by basing everything we do in data. And therefore,
we would all be purely scientific. Unfortunately what happened, which I’ll
soon show, is that the pharmaceutical industry co-opted the so-called science
to convince doctors that opioid prescribing was rooted in science when, in
fact, there is no science to support it. This is a great quote by
William Bruce Cameron which I love, not everything that counts can be counted. And not everything that can be counted
counts, we forgot about this in medicine. All of a sudden it became not okay
to rely on your clinical judgment, your clinical experience or
God forbid, your intuition. Everybody had to wave a number around. And then ultimately, in order to
understand what drive the compassionate doctor, you really need to know
that what makes us get up and out of bed in the morning and
going to work again and again. Is that we’re going to have that
kind of blueberry and I and vow encounter with our patients where we
can realize our identity as a healer and our patients expresses gratitude, it’s
those moments that we really look for. And if we were to challenge our
patient about the way that they’re taking a pill we’re prescribing,
it really threatens that mutual affection that is part
of how docs get their dopamine. Okay, so
let’s talk a little bit about now, shift about what motivates
the drug-seeking patient? For me, what was really revelatory, when
I first started learning about addiction, was to learn something about
the neuroscience of addiction and how the brain changes. So what I’m gonna do is I’m gonna
condense the last 50 years of addiction neuroscience into three minutes at
a level at which I understand it. It will become immediately apparent that
I’m not a neuroscientist, but here we go. One of the most interesting things that
we’ve learned in the past 50 years, about pain and
pleasure is that they’re co-located. So the same areas of the brain
that process pleasure, are the areas that process pain. And the way that pain and pleasure interrelate is that
they work like a balance. Okay, so I really like chocolate. So when I take ingest
a piece of chocolate, my balance tip slightly
to the side of pleasure. But here’s the thing about the balance. It wants to remain level, and
it will work very hard to reestablish a level balance or
what is called homeostasis. And it does that through
a process called neuroadaptation. Now, I kind of imagined neuroadaptation
is these little gremlins hopping on the pain side of my balance
to bring it level again. And that’s that moment of wanting a second
piece of chocolate because the thing about the gremlins is they
like it on the balance. They don’t hop off as soon as
this level but they wait till the balance is tipped in equal and
opposite amount to this side of pain. Again, that’s what I’m thinking, another piece of chocolate
would be really good right now. If I wait long enough, the gremlins hop
off, the balance reasserts homeostasis, and I’m not really creating
another piece of chocolate. That’s how it works, okay? Now imagine that instead
of a piece of chocolate, my doctor gives me some Vicodin. And by the way, I’m in pain, so I’m not even starting out
with a level balanced, right? I’m starting out tilted to the side of
pain, but the balance works the same way. Now I don’t get a little bit of
shift to the side of pleasure, I get a great big shift. Huge amount of dopamine
in my reward pathway. The fundamental difference between
substances that are addictive and those that are not is the amount of dopamine
that they release in the reward pathway. So now, I need a great big
Arnold Schwarzenegger sized grandma on the pain side to bring
my balance level again. But remember, it doesn’t stay there, it slams down to the side of pain
that is called opioid withdrawal. It’s extremely painful for some people. But at last hours today,
depending on how many opioids you took, the gremlin hops off and
homeostasis reasserts itself. Now here’s the key piece to
understanding the disease of addiction. If I take that opioid for days to weeks
to months to years, I have enough gremlins on the pain side of my balance
to fill this entire auditorium, right? Because now my balance is working
really hard to adapt to all those exogenous opioids. So if I can’t get more opioids or
try to say, decide my life is a mess, I wanna stop, guess what,
I slam down to the side of pain, and it doesn’t just take hours or
days for those gremlins to hop off. It takes weeks, to months, to years,
and this is what we call craving. I am now walking around
with this type of balance. I’m irritable, I’m anxious, I’m depressed. I’m maybe even suicidal. I can’t sleep, my life is a lot better. I got my job back, I got my kids back, I got my husband back, but
I feel like crap, right? Theoretically, if I wait long enough,
the gremlins hop off and I get a level balance and
I can enjoy piece of chocolate again. But maybe for some people,
that doesn’t ever happen, which is where we get this
idea that we can use opioids to treat opioid addiction in some cases,
and I’ll get to that. Okay, so now, you understand this
physiologic drive that drives the lying, cheating, and stealing,
which is a symptom of addiction. So addiction is a lot like other diseases,
and in some ways it’s not like other diseases. Because again, there aren’t many
diseases where lying, cheating, and stealing are symptom of the disease
but that’s true with addiction. So patients and people who are addicted will do things
outside of their moral compass because of their addiction that they wouldn’t do
if they were not in their addiction. And one of the things they’ll do is
they’ll try to manipulate their doctor for certain types of drugs. I’m gonna quickly go over some strategies
that I’ve observed in my clinical experience in interviewing other people
in the health care profession that patients use very quickly. These are not meant to be denigrating, it
is meant to be illustrative and memorable. There is the Senator, these are the
patients who use the filibuster technique they wait till the last 30 seconds of the
appointment to ask for a refill because they know it will take you 30 seconds
to say yes and an hour to say no. And they’re very busy and
don’t wanna get behind in their schedule. The sycophant, these are patients who tell you how much
better you are than their other doctor. I used to love to hear
that when I was younger. Now it makes the hair on
the back of my neck stand up. The exhibitionist, so these
are patients who arrive on the ground, who will undress, very demonstrative
displays of pain and suffering. Many of these patients have real pain and
suffering, but they will also demonstrate it. The Dynamic Duo, this is often
the patient and a significant other. In my experience, it’s the patient and
the mother, the mother’s crying, the patient’s writhing,
very hard to say no, two against one. This is the City Mouse and
the Country Mouse. So this is the people on
the other end of spectrum. The city mouse walks into the ED and
says, I’m allergic to all pain medicine except for
IV dilaudid pushed with a Benadryl chaser. The country mouse says, well, my friend got something like I am
a natural codependent, so I say Oxycontin? That’s right, doctor, I know how
to write a prescription for that. And then the loser, these are patients who
will say they lost their prescription, they lost their pills,
water tends to be a common theme here. Went through the rinse cycle,
fell in a toilet, went in the bottom of my fishing boat. The weekender, so these are patients that
are figuring out that we have a very disjointed healthcare system. So they will call in the evenings or
they will call on the weekends, in order to make sure they
get not their regular doctor. The twin,
these are other healthcare professionals. They know we went to the same schools,
we know the same people, this is my personal Achilles’ heel,
other nurses, other doctors. Because I identify with them and
it’s hard for me to imagine that somebody who I
identify with could be manipulating me. The Doctor-Shopper, these are patients
who go around to multiple doctors seeking the same or
a similar prescription. And The Bully,
this is a really tried and true method, these are patients who start yelling,
they threaten to sue. At Stanford they call Patient Relations. Patient Relations calls the doctor,
said we got a complaint. Nobody likes complaints. Okay, so we’ve talked about what
drives the compassionate doctor. We’ve talked about what drives
the drug-seeking patient, namely the disease of addiction. But these individuals are not
working in a vacuum, right, they’re working in this increasingly
complicated healthcare system. What I wanna cover now is
the invisible forces inside and outside medicine that are driving
over prescribing of opioids and other drugs with this very complex
diad of the doctor and the patient. The first one is
the pharmaceutical industry. Big pharma, opioid manufacturers,
opioid distributors. Even in some instances, pharmacies, right? This is a huge and powerful supply chain. Everybody knows that pharma advertises
right to consumers because it works. Everybody know that pharma
advertises to doctors, hats, pans lunches, speakers fees. Even when doctors think they’re not being
influenced, they change their prescribing. But to really understand the genius of
the marketing strategy of the opioid pharmaceutical industry is to
understand their Trojan horse style infiltration of very watchdog
organizations inside of medicine that were meant to protect
patients and recover very quickly. But basically, they identified key opinion
leaders who they knew would promote more opioid prescribing for minor and chronic
pain conditions and propagate their myth. They elevated those individual’s
careers and in many instances, hired them on as consultants. Continuing medical education. Doctors are mandated to attend courses
like these to learn about the latest and greatest standard of care. And they subsidized continuing
medical education, and they still continue to do that. Professional medical societies, so that’s
like organizations that are meant for pain doctors, or meant for
primary care doctors. They subsidize these organizations. Patient advocacy organizations
essentially became front groups for the opioid pharmaceutical industry. The Joint Commission, for
those of you who are in medicine, you will know the Joint Commission. For those of you who are not, very
briefly, this is the organization that sets the quality standards for hospitals
and clinics, so that they can get the stamp of approval, and
they can get medicare and medical funding. Without that,
you will die as a hospital organization. In 2001, Joint Commission said,
you know what? Pain is the fifth vital sign. You have got ask every single patient
whether or not they have pain and you’ve got to quantify it,
because we said it’s a vital sign. So it’s gotta be like science,
and we gotta put a number on it. So we’re gonna give you this pain scale,
zero to ten. Zero’s no pain. Ten’s the worst pain you’ve ever had. You gotta ask every single patient. Turns out using this pain scale
does not improve pain outcomes. What it does do though,
is increase opioid prescribing. Federation of State Medical Boards, this
is the organization that makes sure that rogue doctors who are hurting
patients lose their licence. This organization said, you know what,
if you prescribe a whole bunch of opioids, you’re not gonna be in trouble. Because we know that opioids are safe and
effective. And that furthermore, if you withhold
the opioid from patients in pain, you should get sued for
under treating pain. Under treating pain. Now under treating pain implies that
there’s good treatment for chronic pain. Which it turns out there’s not,
and opioid isn’t the answer. And then again importantly, this is all part of a huge supply
chain that worked in concert. So, I’ve talked about
infiltrating science, infiltrating organizations to propagate
about opioid prescribing, what are those? Let’s go through them. Remember here I’m talking
specifically about chronic pain, because there is good evidence that
opioids work short term for acute pain. So if you get in a car accident,
opioids can be very effective. Short term if you’re at
the very end of life, the last two to four weeks,
opioids are very effective. There is no evidence to support
the use of opioids in chronic pain, which we define as pain everyday for
longer than three months. But here’s what Purdue
taught us in the 1990’s and early when I went to medical school. We now know that many
patients with chronic, nonmalignant pain respond
very well to opioids. The barriers to vastly
improved treatment for hundreds of thousands of people in
pain are simply the misinformation and prejudice of doctors, pharmacists,
and regulatory bodies. This is how I was educated, right? That basically, I’m prejudiced. I’m harming patients if I
don’t treat their pain. Here’s what the evidence
really says about pain. There are no randomized
placebo control trials longer than about 12 to 16 weeks, showing
that opioids work for chronic pain. In fact, what we do know is that
opioids no better than Tylenol. And opioids can actually make pain worse. Because of something called opioid
induced which can change pain thresholds. Myth number 2, no dose is too high,
no duration too long. That’s how I was educated in the 90s. If you’ve got a patient, they respond,
and then they come back and say, it’s not working anymore doc,
just go up on the dose. Myth number 2, opioids are effective, easily titrated, and
have a favorable benefit-to-risk ratio. Large doses of opioids may be needed
to control pain if it is severe, and extended courses may be
necessary if pain is chronic. That’s how we got to where we are today. Tens of millions of patients on
extremely high doses of opioids. What does the evidence
really say about opioids? Opioids taken in high doses and
or long term harm patients. There is mounting evidence of
a dose-dependent risk on opioids. The longer you are on them and
the higher the dose, the more likely you are to
suffer from constipation, depression, cardiac problems,
hormonal problems. Breathing problems,
addiction problems, and the more likely you are to die from them,
even when taken as prescribed. So, overdose is kind of a misnomer because
a lot of people who die from opioids have taken them just as prescribed. Myth number 3,
less than 1% will get addicted and also this idea of pseudoaddiction. So here was really, really dangerous myth. Basically, pharma taught us that as long
as you’re a real doctor prescribing for a real patient with real pain,
there’s kind of magic candle effect. That the prescription pad confers
that your patient won’t get addicted. In fact, if that patient is demonstrating
all the signs and symptoms of somebody who’s getting addicted, they are not
really addicted, they’re pseudo addicted. They’re in pain, just go up on the dose. Contrary to our teaching
addiction is very rare and possibly non existent as a result of
treating such patients with opioids. Psuedoaddiction, appropriate drug seeking
behavior demanding doses before they are scheduled, vicious cycle of anger isolation
avoidance leading to complete distrust. That’s not really addiction,
you need to increase the dose by 50%, assure that breakthrough
doses are available. Complaints resolved when
analgesia is established Project Tango, this was Purdue’s brilliant
idea when they decided they wanted to get into the addiction treatment business. They changed their tune, Project Tango was gonna be their
addiction arm of their business. And then the message was very different. My gosh, opioid addiction can happen
to anyone, from a 50 year old woman with chronic lower back pain to an 18
year old boy with a sports injury. From the very wealthy to the very poor. Amazing how that happens. What the evidence really
says about addiction, one in four patients
>>Taking medication as prescribed for chronic pain, will misuse that opioid and
develop a mild addictive disorder. One in ten will develop
a severe addictive disorder. There’s no kind of magic halo effect
conferred by the prescription pad. And this is just a timeline, showing how long we have known in the
scientific literature that this was true. You’ll see here in 1996,
was when pharma said less than 1% will get addicted as long as
you’re treating pain and you’re a real doctor and
they’re real patient no, wrong. We’ve had a lot of evidence for
a long time, that patients can get addicted
even when they’re taking it for a bonafide medical condition
even when they have real pain. Myth number four, dependence is benign and
easily reversible. So this is an important point. We have lots of people in this country
who are not addicted, but who are on high doses and who are physically dependent and
who will struggle to get off. Another thing that pharma said is that,
when people get dependent, that’s just sort of normal. That’s like people needing insulin for
diabetes and you just take them off it and just
taper down over a week and no problem. Turns out not so much, right? Lots of patients who don’t meet
criteria for addiction, but have been taking opioids every day, really
struggle to get off of those opioids. Because their body has adapted whoops. Dependence is really no joke as I could. Here’s what produced that tolerance and
physical dependence or normal physiologic consequences of extended opioid therapy,
and must not be confused with addiction.>>[LAUGH]
>>Dependence though in truth is no joke. This is a sort of a summary of
the literature out there showing opioid naive patients exposed to
opioids in the course of surgery. Look at these numbers, the percentages who will be what’s called
Persistent Opioid users a year later. These are not people who have addiction,
but these are people who can’t
stop taking their opioids. I am always struck by
this one by Harbaugh. These are pediatric patients, right? So kids who were exposed to
opioid because of a surgery. 5% of them, that’s a really high
adverse health consequence in medicine, will still be on opioids a year later. And these are not medical
interventions and surgeries that would require opioids for
a year. Okay, what did the evidence really say
about tapering dependent patients. Well it turns out when you take this
population of opioid dependent patients, and you slowly taper them down guess what,
their pain gets better. To me there is almost no better proof
that opioids make pain worse and that we have people that when you go down,
their pain gets better. Now, patients don’t believe
it when you tell them. And they don’t wanna go down, but I can
tell you from my personal experience and the growing literature, pain gets
better when people decrease their dose. Myth number five,
risky patients can be screened out. So here’s what Purdue said. Are opioids always addictive? No, watch out for
those cherry syrup addicts! Cherry syrup addicts. That refers to people who take methadone
maintenance, which comes in liquid form. So that was a very clever move. You know what, there are all those like
yucky addicted people over here but, just like screen those people out and then
these wonderful people are good patients. They won’t ever get addicted. And the truth is that
existing screening tools, to separate out people who
are more vulnerable or less vulnerable to addiction,
are really no better than chance. What that translates into is that
people with a history of addiction, won’t necessarily get addicted to
the opioids that we prescribe. And people with no history of addiction
are the risk factors may get addicted. In other words we need constant
monitoring, we can’t just do some paper and pencil screen before we started them
and then we are good to go for the next 10 years, these are the of opioids
prescribing, I went through all of them. That’s the invisible impact of big let’s
talk about some of the other invisible forces driving opioid over prescribing. One of them is what I call
the Toyota-ization of medicine. It’s one of the big changes in medicine,
in the last 30 years is a mass migration out of physician owned practice into
large integrated healthcare centers. So the majority of physicians today are
actually salaried employees as a result, we practice protocol as medicine, right? We have guidelines, we have protocols,
we have algorithms. And what that has led to when
it comes to opioid prescribing, there’s enormous pressure on doctors to
palliate pain, to prescribe pills and perform procedures because that’s what
third party payers will reimburse. To protect privacy and to please patients. We’ve essentially become waiters and
our patients have become our customers. A couple of years ago, my then 11 year old son decided to
Google my name on the internet. He said mom, is this you? He didn’t seem too please
about what he had found. And I went over there and
I had this review would mean, you know what Corey here
had to say at the bottom. I don’t remember Corey. She provides the kind of care that would
make you wish you had never sort help in the first place.>>[LAUGH]
>>Wrong diagnosis. Wrong medication. Some cases just could be terribble. Seek help from someone else. I mean I was modified of course,
my 11 year old son found that. Who else had seen that? This is the major driver. I’ve been all around the country
in the last 34 years, talking to doctors urging them to
prescribe opioids more judiciously. And they will come up to me and say, I’ll prescribe fewer opioids when you
can promise me that I’ll still get good reviews on my patient
rating satisfaction surveys. Cuz if I don’t, I will lose my job. And this is no joke, okay? These ratings really matter. I can tell you in my job if I get
too many bad ratings from patients, I get called to the table. What are you doing wrong Dr. Lembke? What’s going on with you and your patient? In fact, there’s no evidence to show. That if you get high patient satisfaction
surveys that your patients have better health outcomes. Indeed this data point, suggests that
patients who rate their doctors more highly, are more likely
to overuse healthcare, take more prescription drugs and die,
even when controlling for morbidity. So, that’s a problem. Now the good news for me is that my
son did come out a few minutes later, he said don’t worry mom,
I just gave you four out of four stars.>>[LAUGH] [APPLAUSE]
>>Twice>>[LAUGH]>>Okay, another invisible force driving. Over prescribing is
the medicalization of poverty. So this has been a really fascinating
thing that I have observed in my 30 year medical career. Basically, doctors are increasingly
asked to care not just for their patients biomedical problems,
but also for their psycho spiritual associate economic problems, but
we’re not given the tools to do that. So we biomedicalize things that
are not in fact medical, and then once we’ve done that we give a pill. And there’s evidence
to show that Medicaid, which is the federally funded disability
for people who are poor in this country. For Medicaid patients opioids
are prescribed at twice the rate of non-Medicaid patients, and Medicaid patients are more likely
to die from an opioid overdose. If you look at this heat map,
which you’ve seen before. Remember, darker is more
opioid prescribing. Just look at it, get a Gestalt from where
there’s a lot of opioid prescribing, and then look at this US
unemployment by country. And you’ll see a very similar pattern. So in places where people
are economically in trouble is also the place where there’s
more opioid prescribing. It’s also true that where there are more
doctors, there’s more opioid prescribing. That’s another interesting data point. Another huge change we’ve seen is this
mass migration on to the disability role. So disability is for people who have
can’t work because of medical problems. But essentially,
disability has become the new welfare. We had 150,000 people
getting SSDI in 1957, main reasons were cancer and
cardiac disease. We have over 8 million
people on SSDI today. Main reasons re mental illness and
musculoskeletal disease, aka chronic pain. I frequently see patients who are not
interested in getting better. They need a certain type of prescription
and a certain diagnosis to validate their pay cheque, because being a patient has
become their job and I don’t blame them. Because it’s the only way that they
can survive without any other kind of social safety net. Karl Marx said religion is
the opiate of the masses. We’ve gotten to a point where now
opium is the religion of the masses. You may be familiar with
the work of Case and Deaton. They are the Princeton economist who have
coined this phrase death of despair. They’ve shown increased mortality
in white middle aged individuals. Number top three reason for death,
there’re suicide, alcohol or liver cirrhosis, and drug overdoses. Okay, finally another
invisible force driving or prescribing is new narratives about pain. Okay, what we think of in our culture
is a tolerable or appropriate or amount of pain? And basically the narrative that we
have today is that pain is dangerous. That pain experienced in any form,
whether psychological pain or physical pain, leaves the kind of psychic
scar that sets us up for our future pain. The classic example is
post-traumatic stress disorder, but also we have a whole bunch of new
chronic pain, centralizing syndromes. This is very different from how we
used to think about pain, right? This is a very modern concept. In fact, 150 years ago, when general
anesthesia was first being invented, some of the leading surgeons in this
country were reluctant to adopt it because they believed
that pain was salutary. They believe that it boosts
the immune response, boost to the cardiovascular response. What doesn’t kill you makes you stronger. We could no more say
that to a patient today, then we could fly to the moon,
we can fly to the moon, but anyway. Here’s a great example of
what I’m talking about. This was an individual who
walked into an emergency room. And he was jumping up and down, he had his
construction worker, he jumped on a nail, he had terrible pain. They gave him boatloads of opioids,
none of it worked. Finally, they gave him more and more, and he was sedated when they pulled
the nail out and took the shoe off. They found that it had
gone between his toes.>>[LAUGH]
>>Right? But he had this construct
of pain in his mind. Now we have trained several generations
of patients to focus on their pain, to get anxious when they have pain, and
to believe that they can’t feel better. As kind of a corollary a very
famous study from Beecher, who looked at soldiers on
the on the World War II front. And found that these are soldiers who had
like gaping wounds, their guts spilling out, their limbs flung a mile away from
where they were because of injuries. Two thirds of these
individuals had zero pain in the immediate aftermath of their injury. How can that be? Because the meaning of their pain was
number one, they were dead and number two, they were going home. My point here is the way
that we talk about pain. The way that we conceptualize pain has
a huge impact on how we experience pain. And in modern medicine, pain is dangerous. Look at what Thomas Sydenham had
to say about pian in the 1600s. I look upon every effort calculated
totally to subdue that pain and inflammation dangerous in the extreme for
certainty a moderate degree of pain and inflammation in the extremities are the
instruments which nature makes use of for the wisest purposes. Today, we don’t have narratives like that. In fact, our narrative is the body cannot
heal itself, that doctors especially when aided by technology have a superhuman
capacity to heal anything, and that victimhood is a right
to be compensated. So now I hope you have a good idea of
what motivates the compassionate doctor, what motivates the drug seeking patient, the invisible forces inside of medicine
that incentivize over prescribing. And then finally, let’s look at what
happens when that doctor and that patient get in the room and have to have an
interactions around the prescription pad. Basically they’re both caught between
a prescription and a hard place. This generates anxiety for the doctor. The doctor then enlists his or
her primitive defense mechanisms. Just to refresh your memory, defense
mechanisms are unconscious strategies, so we don’t know that we’re doing them. That we enlist to dissipate
negative emotions, right? Because negative emotions
are uncomfortable. Different from coping strategies like
I’m going to do my mindfulness breathing exercise now, so that I can calm down,
that’s a coping strategy. A defense mechanism is more primitive, it’s actually very adaptive
in some emergency situations. But as a chronic coping style,
not so much. Here’s a common defense mechanism,
denial, like this isn’t happening. I’m a good doctor, my patient’s not getting addicted
to the pill I’m prescribing. Projection, this is where I
take a negative emotion and I put it on the other person
because I don’t wanna own it. So instead of owning that I,
as aphysician, am feeling rageful toward this patient,
who is getting addicted, why am I rageful? Because I don’t know
how to treat addiction, cuz I didn’t get trained
on it in medical school. I instead project my anger
onto the patient and say, that person has borderline
personality disorder. Get her out of here. Splitting, this is where I divide my
patients into my good patients and my bad patients. My good patients, those are patients who
have really straightforward problems that I learned about in medical school and
they bring me chocolate at Christmastime. Bad patients, addicted patients, patients
with complex mental health problems. Patients with multi generational trauma,
patients I don’t know how to help. And passive aggression most commonly
manifested is procrastination, these are the patients I delay and
avoid, you should come back next week, I told them to come back in three months
>>[LAUGH]>>So what happens when primitive defense mechanisms no longer work? So we have something called
the prescription drug monitoring database. We can go on there and
see all the prescriptions for controlled drugs the patient has
gotten in the last 12 months. We’re now mandating in
the state of California, and in many states as the result of this
opioid epidemic to check this database. And when we do, and we see, my gosh, I’m the fourth doctor this
week this person has seen. What are doctors doing then? Well guess what? it’s not good either, Because then they’re
experiencing a narcissistic injury.>>[LAUGH]
>>So you do not need to be a pathological narcissist to experience
narcissistic injury. We’re all vulnerable to narcissistic
injury when our competence is threatened. So whether we are trying to be
a good parent, or a good doctor, or a good birdwatcher, when our
competence is threatened in that arena, even in a very subtle way,
we can experience that core injury. Usually unconsciously, and the most common
reaction is narcissistic retaliation, when we get angry at the person
who caused the injury. And so what’s happening, as I alluded
to before, is a lot of patients are just getting kicked out of clinics or
doctors are just refusing to treat them. The phrase opioid refugees has been used
to describe this population of people, now wondering clinic to clinic. And again this is just an example showing
that 40% of these patients are being turned away. There is even a FDA Warning that
show that you can’t just discontinue opiods in these patients,
they’ll go into acute opiod withdrawal. Okay, we made it this far. Five more minutes. How can we fix the problem? Very quickly, we have to stop the pendulum going from enabling to retaliate
against this patient population. And we have to do the same thing
we would do for any epidemic, whether it’s opioids or
tuberculosis, primary prevention, secondary prevention,
and tertiary prevention. Just very quickly, primary prevention means trying
to limit the number of new cases. Fewer opioid starts, right? Not exposing people to opioids
through a prescription for them, or to their family members, and neighbours,
and friends through leftover pills. A lot of good work being
done in this space, you saw that opioid prescribing has
gone down and that’s really awesome. And there’s even a lot of really
interesting work using local anaesthesia and alternative anaesthetic
techniques during surgery to limit opioid exposure during surgery. Cuz we know surgery itself can be
a gateway to opioid dependency and addiction. Secondary prevention. So this is trying to limit the harm
in people who are already vulnerable. So remember I alluded to that population
of people who are dependent but not addicted, who are on very high doses,
who are not benefiting, but who are taking them everyday. We need to help this population slowly
taper down or maybe all the way off. Remember I said that we have evidence
showing that when people get off of opioids, people with chronic pain,
the chronic pain actually gets better. But we’re making a really big
mistake with this population. We’re just cutting them off,which isn’t
helping them or going down too quickly. I have patients on a year or
three of their opioid taper. Because it’s a really painful process and they need a lot of support,
they need a lot of coaching. They need alternative treatments for pain,
insurance companies have to pay for it. And a lot of the need,
mental health treatment also. And then, tertiary prevention,
treating cases, right? We have to treat the people
who’ve become addicted, we have to use all
the tools in our toolbox. I know when I first came to this work,
I was really, really reluctant to use medications like
morphine or methadone, these are opioids. I didn’t wanna just be giving opioids,
people are opioid addicted, but guess what? There’s a lot of robust
evidence across continents and decades showing that opioids, special
opioids that have special properties to treat opioid addiction,
decrease the use of illicit opioids. Stabilize well being in people’s lives,
decrease transmission of HIV and hepatitis C, and
improve overall quality of life. So really, really important that
we not out right reject that, even though on some instinctual level it
is uncomfortable to think about giving opioids to people with opioid addiction. And then obviously we have to do a lot
more around these invisible incentives that are driving opioid prescribing,
right? We have to make sure that insurance
companies pay doctors to spend time with patients, to talk with them, to provide
non-opioid alternatives to the treatment of pain,
to provide mental health treatment. And we have to do a much better job
educating doctors about addiction. I didn’t learn anything about addiction
when I went to medical school. Even in my psych residency,
learned nothing about addiction. Who taught me about addiction? My patients did, when one of them
almost died because I was clueless and never even asked her about her addiction. I’m gonna stop there. Thank you so much.>>[APPLAUSE]

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