Anna Lembke on the Opioid Epidemic

Anna Lembke: Right. In 2016, somewhere between 50,000 and 60,000 people died of a drug overdose, and of those, 50-75% were attributable to opioids. And about half of those opioids were prescriptions. But I think it’s important to recognize that what began as a prescription opioid epidemic has greatly expanded the number of people using heroin as well.

AL: Well there are so many opioids out there in the community because of the over-prescribing problem and that access alone has meant that many more people have taken opioids. From teenagers taking it out of their parents’ or their grandparents’ medicine cabinets, to kids trading pills at school, to having it prescribed by your doctor for some minor procedure—this has normalized opioid use and made it relatively easy to obtain.

People are getting exposure through a prescription—either their own or somebody else’s—and, particularly for young people, transitioning to heroin isn’t that big a leap. They want more and it is easy and cheaper to go to heroin.

The big spikes in heroin use that we’ve seen in the last five years or so have mostly been among the 18 to 25-year-olds, and I think some of that is driven by a cultural phenomenon in which young people aren’t as afraid of heroin as the older generation. People in their 40s, 50s and 60s, for them to go to heroin would be crossing some kind of line that doesn’t fit with their identity.

On the other side, in the last five years or so there’s been a crackdown on opioid prescribing, and some people who had been receiving very high doses for a very long time all of a sudden have found themselves unable to get the opioids that their body and brain had gotten used to. Some of those people then turn to heroin.

AL: Yes, they are.

AL: Right.

AL: Unfortunately that has happened. In trying to highlight the dangers of over-prescribing, one of the unintended consequences is that the pendulum swings too far in the other direction. Doctors decide they’re not going to treat pain patients or prescribe opioids for anyone anymore. It’s unfortunate. A lot of my professional time right now is taken up with educating physicians about the “middle path”—prescribing judiciously while not enabling an addiction, and not reacting or retaliating in a way that means people aren’t getting the care that they need.

AL: Thank you so much for saying that. It means a lot to me. And thanks for your openness about your own struggles.

AL: You can say that again. I went through medical school in the 1990s, and the extent of my addiction training was being instructed to attend one AA meeting. Honestly, it hasn’t gotten much better.

AL: I’m so embarrassed when I look back at the kind of doctor I was. I mean, I’m a psychiatrist. Here I was purportedly wanting to help people struggling with mental illness, yet I really did not consider addiction an illness of any kind, and I didn’t think it was in my purview to treat people with addiction. I thought that was somebody else’s problem.

AL: I don’t even know. Just not me. What’s so fascinating is that my dad was probably, in retrospect, a functional alcoholic. He was a surgeon, and he was a very serious binge drinker. He was never professionally diagnosed or treated but he had a serious drinking problem, so part of my rejection of this patient population came out of a negative transference—“I’m not going to deal with those people.”

We all have a story like that. Whether it’s our own addiction or somebody in the family, we don’t want to look at that piece of ourselves or that part of our family history, and our patients suffer because of it. And we’re in a system that to a large extent still doesn’t view it as an illness but rather as a form of moral corruption or a weakness of will. It makes it hard for us to look at our own stuff.

AL: It’s such an exercise in denial for psychiatrists to think that they could make a complete diagnostic evaluation and not ask about substance use, but that happens more often than not. And it’s not just psychiatrists, but other types of physicians, too. We know at least 50% of people who show up in the emergency room with severe trauma have been using substances. Primary care doctors and oncologists see addiction problems. People with cancer get the big C-card pass, but I know a lot of people with cancer who have serious substance use problems. So we all need to be asking those questions of our patients right from the start.

AL: Psychotherapists and other non-prescribers in the mental health care field can play an absolutely vital role. In many instances, doctors today are so pressed for time and often don’t have the kind of trust that counselors have built up over time seeing patients regularly. You guys hear the real stuff that I, as an MD, often don’t. But I would also say that in my experience, even in the limited time I have with patients, on some level they’re dying to talk about it. All you have to do is just ask the question, and they will tell you, and they’ll be so relieved to be able to share it.

The bigger problem is that we’re not asking the questions. All of us, including psychologists and non-prescribers, need to ask about substance use, including prescription drug misuse. Then the vital role you can play is—with the patient’s permission—call the prescriber. In most cases, if it’s done with a reasonable amount of humility, the prescriber will be grateful and even thrilled.

Let me just give you an example from my clinic just today. I had a man come in, and he is in recovery from an alcohol and cannabis use disorder, has been in recovery for many years. He also has Attention Deficit Disorder. He went to see a psychiatrist at Kaiser who prescribed him 30 milligrams of Adderall. He stayed at 30 milligrams for about six months, and slowly the dose was creeping up. And now he’s at 90 milligrams a day, running out two weeks early, having to white-knuckle it until he goes back and sees the psychiatrist, who then fills his prescription for Adderall.

I asked him, “Have you talked about this with your psychiatrist?” And he said, “No, I haven’t. I know I should. I just haven’t been able to get up the courage to tell her that I’ve essentially relapsed on the pills that she’s prescribing.” And then I said to him, “Well, now that you’ve told us about it, would you be willing to talk with her and let her know?” He said, “Yeah. I really need to. I really want to. I would be willing.” But there was some hesitation in his voice. And then I said to him, “Well, how about if I were to call her? Would you be comfortable with that?” And he said, “That would be so great. If you could just call her and tell her that—because I’m not sure if by the time I get to my appointment I’ll be able to do it.”

And then I said to him, “Well, how about if I called her right now while you’re here? Would you be okay with that?” He said, “That would be great. I would love it if you would do that.” So I called her up, and I said, “Hey, I want to let you know patient X is here and he’s really appreciated your care, and he feels so much shame and embarrassment, but this is what happened, and he wants you to know.” And then I said, “This is my name, this is my number. Please call me. We want to help.” It’s not, “You’re so dumb that you missed this. You’re a bad doctor and I’m good doctor.” I’ve been duped a million times. I’m not a mind reader.

Of course, it’s not that every patient every time will say, “Oh, yes. Please call.” Many times they’ll say, “Oh, no. That’s okay, don’t tell my doctor. I’ll take care of it.” But the truth is, sometimes they will say, “Yes, I’m ready. Please help me with that.” And if you don’t ask and you don’t offer to interface, then they won’t suggest it.

AL: Let me tell you something else that I’ve learned to do over the years regarding this whole issue of shame. I have a patient who had been in recovery from her alcohol addiction for six years, and just relapsed in the last six months, and she gets sober for a week and relapses, back and forth. She had been sober for about a month and then I just heard that she relapsed again. She left a message and just said, “I relapsed and I’m not going to come in today because I need to go to rehab.”

One of the things I’ve learned is when you get that kind of message, don’t just be okay with them saying, “I’m not coming in. I’m going to rehab.” What that actually means is, “I’m going to sit at home drinking until somehow, by some miracle, I get into rehab.” So I said to my residents, “Call her. Tell her we need to see her at her appointment, and tell her to bring her family.” So she showed up at her appointment and she brought her family and the first thing that I did when I walked in the door was to give her a big hug, and I said, “I’m so sorry. I’m so sorry.” Because to me—and this is the key take-home message—somebody who has the disease of addiction and relapses is exactly the same as somebody who has cancer that was in remission and gets a recurrence of their tumor.

What would you do if you walked into the office and somebody had a recurrence of their cancer? You would say, “I am so sorry,” and you would give them a big hug. And that’s exactly what we need to do with addicted patients, because that’s exactly how it is for them. It’s exactly like that. And they’re so appreciative. “Oh, my God,” she said, “Thank you, thank you,” and she was crying. She was devastated, absolutely devastated that she’s relapsed. She’s not going, “Oh goody, I relapsed. I got to get high.” It’s not like that.

AL: Conceptualizing it as a disease is a really helpful way to maintain a compassionate frame of reference. And then the other piece of it is just being really transparent with patients. “If you lie then I can’t really help you. At least tell me the truth about what you’re doing, and let’s talk about some strategies or what we might do.” In general I find that if patients show up, they’re happy to talk about it.

Compassion can also open up a sense of awe. It’s like, “Oh, my God. What a horrible disease. You really don’t want to be doing this, and yet here you are.” As they say in AA, the disease is “cunning and baffling.” And it is. Awe may not be the right word, but to really recognize the power of addiction, the grip it can have on people.

AL: Yes. And it’s important to be able to really witness the tragedy of that.

AL: You know, the more I’m in this strange profession that we’re in—it’s kind of a wonderful and weird job—the more convinced I am that I have no idea who’s going to get better. When I was younger I thought I could tell, but I’ve had too many experiences where someone comes in and I totally identify with them and think, “Oh, a slam dunk. I know exactly what to do. They’re going to be better in a month.” Those have been some of my worst outcomes.

And then I get people who walk in my door and I just think, “Train wreck.” And I literally pray for them. I don’t know what you do; I pray to God. I’m like, “Please, God, help me, because I don’t think I’m going to be able to help this person.” They’re telling me their story and wanting me to help them, and I’m thinking to myself, “I have no idea how I’m going to help this person.” Can you relate to that?

AL: Sometimes those people are the ones who get better. It’s so unpredictable.

AL: Oh, absolutely. Addicts will often see psychiatrists and therapists and talk about everything under the sun—every last thing their mother or father ever did, every dream they’ve had—but they won’t talk about their substance use. People who are shooting up heroin. It happens so often. It’s not a minor issue.

Across the country, medical schools are working hard to try to revamp their curriculum to incorporate more addiction training. We’re certainly doing that here at Stanford, working very hard to at least get the basics to our medical students so they can go out and not harm patients because of ignorance.

But that’s the state we’re in right now: Patients are actually being harmed. Not because most doctors are bad people, but because most doctors are very ignorant about this disease and so, inadvertently, cause harm by ignoring it—or worse yet, aiding and abetting it by prescribing in a way that’s not safe for the patient.

The former director of the Office of National Drug Control Policy, Michael Botticelli, is in recovery. I went to a symposium at the White House where he was one of the main speakers, and he said something along the lines of, “I look forward to the day when I, as somebody in recovery, don’t have to explain to my doctor what recovery is and how he or she should treat me.” I thought that was eloquently said.

AL: No.

AL: I mean, pain has gone through a fascinating evolution in the history of medicine. Prior to 1850 or so—which is also prior to anesthesia and convenient forms of analgesia or pain relief outside of drinking some whiskey—doctors actually believed that pain was healthy for the body, that experiencing some degree of pain, let’s say during a surgical procedure, would boost the cardiovascular system, the immune response. And there was a very prevalent idea that, on a spiritual level, pain had benefits for people. This idea that “what doesn’t kill you makes you stronger.” Over the course of the last century and a half or so, that has really changed, not just in medical culture but in society as well. We now consider pain to be a dangerous phenomenon in part because, well, it’s painful in the moment. But there’s also a widespread idea that we’re very fragile creatures, and that if we experience pain in the moment it will set us up for future pain.

The quintessential example of that is Post-Traumatic Stress Disorder (PTSD). It’s based around the idea that if we have some kind of emotional distress, it will leave a psychic wound that will cause emotional distress and suffering in the future. I think it’s important to recognize that that is a very modern idea. Prior to about a hundred years ago, people never thought about emotional distress and pain in this way. I’m not saying they didn’t have plenty of traumatic experiences but it wasn’t conceived of as “trauma.” They dealt with it in different ways and it may even have been kind of a badge of honor to be a wounded warrior.

But that is not at all how we think of it now, and I think that this new ethos of people being fragile and pain being dangerous has really helped drive the over-prescribing of all kinds of potentially addictive drugs, from benzodiazepines to opioid analgesics. This idea that we have to eliminate all pain and we have to do it immediately and, especially as healthcare providers, that we are remiss in our duties if we don’t. Not all healthcare providers agree with that mentality, but it is so dominant and pervasive in medicine, and especially in the mental healthcare field, where, if we’re causing them to feel distress or suffer in some way, then we’re not doing our job.

AL: Absolutely. And yet, these paradigms are dialectics. The pendulums swings one way, and things don’t quite work, and then they swing back. Dialectical Behavioral Therapy (DBT)—speaking of dialectics—has been enormously helpful for certain types of patients, in part because what it teaches is distress tolerance.

It’s not just people with mental illness who need distress tolerance, though, it’s all of us. We’re so insulated from any kind of painful or distressing experience that we’re deficient in distress tolerance. DBT puts it front and center and says: We’re going to teach you distress tolerance. When you’re suffering physically or emotionally we want you to sit there. Sit in that moment. Or we want to have you stick your hands or your face in an ice bucket to distract yourself. This is a fascinating movement and a potential antidote to this idea that all pain needs to be eliminated.

AL: Great question. Thanks for setting it up that way, too, because there’s no one-size-fits-all treatment. Having access to a bunch of different modalities is the ideal situation, because what works for one person is not going to work for someone else. AA may be the secret to recovery for one person and be an absolutely terrible fit for another.

A lot of patients will come in and want some kind of magic pill. We do use pharmacotherapy medications to treat addiction—although they’re generally underutilized by healthcare providers and should be utilized more—but there is no magic pill.

AL: Not just that. Also Antabuse, Vivitrol, Suboxone, Naltrexone, Campral for alcohol use disorders, nicotine replacement and other modalities for nicotine use disorders. These medications are underutilized, but they are not magic pills.

We have to talk a lot about how addiction is a biopsychosocial disease, and that the best treatment for the biological part is abstaining—not using the drug of choice for a period of time or maybe forever, depending upon the person, so that the brain can reset itself. And then the psychosocial piece, the long-term psychological and social interventions that are really the most important pieces.

We’re moving increasingly away from recommending that people go to 30-day rehabs. There’s definitely a time and a place for that, but we’re emphasizing, “Can we find a way to help you not use addictively in your regular life?” If we remove you and put you in a residential facility, you might do great during that time, but when you get out you have to return to the real world and your life. So initially, and also for the long term, we're looking for how to help people change their lives while they’re still in their lives.

That requires a lot of creativity from patients, too. So much of their substance use is ingrained in their daily living and so the key is to figure out, “How can I change my routine, my environment, the people I connect with? How can I change my internal life, my external life, on a very deep level?”

AL: For someone like that who doesn’t necessarily self-identify as having an addiction but who strongly self-identifies as having a pain disorder, and who has been on opioids for a long time, prescribed by a physician, I probably would go to buprenorphine, which is a special opioid that we can use for pain. It’s FDA-approved for the treatment of pain, and also FDA-approved for the treatment of an opioid use disorder.

AL: Yes. Absolutely. Because, number one, the data are convincing that, for some people, the risk of relapse is just too high when they try to go off of opioids. And from a biochemical or neurological point of view, it just makes sense that after years of exposure to opioids, that the brain, no matter how much time off of drugs you give it, is not going to reset itself. And those are people for whom opioids is the only way that they can feel normal in the world.

AL: Well, for pain theoretically, too, if you have the right kind of opioid. Both buprenorphine and methadone have unique properties, but the problem with methadone prescribed in pill form is that it has a really high overdose risk, so it’s not safe. It’s only safe when prescribed from a methadone maintenance clinic. But buprenorphine is a really unique drug, which makes it pretty good for pain, though many people develop a tolerance and end up needing more and more. And there may be—God forbid I say this—some people for whom chronic opioids for pain work. I don’t see those people, but I believe they’re out there.

AL: I don’t want to throw the baby out with the bath water. I think the "stages of change” idea can be very helpful for clinicians as well as patients, but I think it can also inadvertently provide an excuse not to get in there and move toward treatment. There’s no actual evidence that the stage of change that somebody is in predicts their engagement in treatment or their outcome. When people are mandated or forced for one reason or another to engage in treatment, even if they’re in a pre-contemplation stage, they don’t necessarily do any worse than people who are in an action stage.

AL: Isn’t it? it’s a fallacy that people have to be “ready for change.” I mean, if we waited until every pain patient on opioids was ready to change, we’d have even more people dying.

One of my great mentors in the addiction field felt that one of the most important things that he could do when he walked into the room with a patient was to shake them up. Get them off balance instead of agreeing with them and throwing soft balls. He’d be like, “You know what? That’s just ridiculous.” Often he would just leave, and they would be angry at him. But that’s the kind of unsettling experience that sometimes—if it’s done empathically, obviously—can make a big difference.

AL: One of the big differences is that in many instances, patients have been getting their heroin equivalent from a doctor, so it’s very hard for them to shift from self-identifying as a pain patient who is getting treatment to somebody who’s become addicted. The way that I work with that is to really normalize the process and just say, “Hey, I totally get that you have pain, and this was started by a doctor for a real medical condition, but it happens that this is also a very addictive medication. And what we’re seeing now is that many people—even when receiving this from a doctor—have gotten addicted.” And then I always emphasize that it’s nothing to be ashamed of, that it’s not their fault and that they’re not alone.

Big Pharma did a good job teaching doctors something that wasn’t true, which is that the risk of getting addicted was less than one percent, as long as it was prescribed by a doctor. Now we know that’s not true. Probably about a quarter of patients who are prescribed an opioid for more than three months, even for a bona fide medical condition, will develop some type of prescription opioid misuse problem.

AL: Yeah. Twenty to thirty percent of people prescribed opioids daily for more than three months will develop some kind of opioid misuse problem. The longer it’s prescribed and the higher the dose, the more likely they are to develop a problem.

AL: Well, not always. That element of denial is part and parcel of addiction. I think the difference is that the opioid epidemic has involved institutional denial. Now things are shifting as we realize that people can get addicted to opioids even if the doctor prescribed it. On the other hand, alcohol really has not ever been considered medicinal, except in rare instances.

We have the same problem now with cannabis. Because we have medical marijuana, someone will come in, a young person with no identifiable, objectively verifiable disease process, telling you that their 12-times-a-day cannabis use is “medicinal.” It’s very hard to combat that narrative because it’s a prevalent narrative in our culture. This is where this biopsychosocial model of addiction is so interesting and important. None of us lives in a vacuum. We live in the world, and our autobiographical narratives about our lives and why we do things are informed by the culture and the economics and the time in which we live. And we live in a time in which we believe in better living through chemistry. Whether it’s a medicine that a doctor prescribes or a medicine that I get from my friend in my study group at college, we have this idea that using chemicals to change the way you feel is perfectly okay.

AL: Very true. But every day in my clinic, I see many examples of people who do get addicted to pot and who realize it and are coming in for help.

AL: I think it’s important to recognize that we’re in an era of twelve-step bashing. It’s very clear that twelve steps is down and getting kicked. The program came into being in part because the medical profession wasn’t doing anything to help people with addiction. People had to figure it out for themselves and it turns out that the AA movement is one of the most remarkable social movements in modern history. It’s really an incredible, incredible movement. You can go to an AA meeting pretty much in any country in the world. How many things can you say that about? It’s absolutely amazing.

But I think this sort of one-size-fits-all dogmatic approach to problems of addiction is what caused this quite vituperative backlash toward AA, and as a result, people are throwing the baby out with the bath water. The truth is that for people who actively participate in AA—AA in particular, but other twelve-step programs probably as well—they have very good outcomes. Their outcomes are better long-term than engaging in individual psychotherapy or group psychotherapy or really any professionally mediated treatment you can identify. So it’s a very robust phenomenon for those who actively participate—and that’s a key feature because not everybody does.

If someone goes to three AA meetings and then doesn’t go anymore and says, “AA doesn’t work,” that’s a misrepresentation because that person hasn’t actually engaged in the program. Those who engage have better outcomes. I’m always thrilled if I have a patient who’s actively engaged in AA because I know already the culture that they’ve been immersed in, the learning that they’ve done. It’s so helpful for me as an addiction specialist to be able to tag onto that and dovetail with that and reinforce that. I’m not in recovery myself, but I’ve personally worked the twelve steps in part to understand what they’re all about, and in part because I think they’re really useful for a lot of different problems.

So I can converse with my patients on a pretty good level for somebody who’s not in recovery about what step they’re on, if they’re working with their sponsor, how that relationship is going, how meetings are going. I think it’s really important to be able to do that. It creates continuity between their twelve-step life and their professionally mediated addiction treatment.

Do I think twelve step works for everybody? Absolutely not. But another great advantage of twelve steps, which I think is underappreciated, is that it has incredible access. It’s everywhere and it’s free. And you can go when you’re intoxicated. There aren’t many clinicians who can say that. I also say to patients, “If you get yourself a good sponsor, that’s somebody you can call at midnight. Can you call me at midnight? No. I’m not going to pick up, and I’m probably not going to respond until later the next day. You call your sponsor at midnight, and they will be there for you.” That’s pretty amazing. There’s so much wisdom in the twelve steps—the cumulative wisdom of people in recovery, it’s awe-inspiring, really.

AL: Right. I can’t. If I could, I probably would. But I can’t.

AL: Many roads to the top of the mountain. And we should really appreciate what each one has to offer.

AL: I put together a free online CME course through Stanford, which talks about the neurobiology of addiction and the prescription drug epidemic. That might be helpful. And then we’re making a course now that should be coming out soon about how to taper patients off of opioids, benzos and really anything that’s habit forming. It’s focused on the psychological aspects of preparing patients for it and I think even non-prescribers might find that helpful.

Also, the California Society of Addiction Medicine (CSAM) is a great resource for learning more about addiction. We have an annual conference every fall. This year it’s in San Francisco in August. For any practitioner, PhD, MD, MFT, etc., who wants to learn, it’s a three-and-a-half-day blitz course on addiction. It’s a great resource and taught me a lot about addiction treatment.

AL: It was a pleasure.