Welcome back to the Healing Pain Podcast with Anna Lembke.
It’s great to be here with you again for another week where we discuss integrative strategies for healing chronic pain naturally. Each week, as you know, I try to bring on a different guest from healthcare. A different guest who can really talk to both practitioners, as well as people who’ve had chronic pain and how we can obviously deal with our opioid epidemic, how we can deal with our chronic pain epidemic and just to bring in different mindsets and experience.
Once I heard today’s expert, I was really excited and I said, “I have to get her on the Healing Pain Podcast.” Let me tell you a little bit about her. Her name is Dr. Anna Lembke. She received her undergraduate degree in Humanities from Yale University and her medical degree from Stanford University School of Medicine.
She completed her residency in Psychiatry and a Fellowship in Mood Disorders both from Stanford and is currently Chief of Staff for Addiction Medicine Dual Diagnostic Clinic. She has published over 50 peer reviewed articles, chapters and commentaries, and is author of the new book, Drug Dealer MD: How Doctors Were Duped, Patients Were Hooked, and Why It’s So Hard to Stop.
About Anna Lembke, MD
Dr. Lembke received her undergraduate degree in Humanities from Yale University and her medical degree from Stanford University School of Medicine. She completed a residency in Psychiatry, and a fellowship in mood disorders, both at Stanford, and is currently Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. She has published over 50 peer-reviewed articles, chapters, and commentaries, and is author of the book: Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop (Johns Hopkins University Press, November 2016).
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Drug Dealer, MD; Doctors Duped, Patients Hooked, How To Stop It
I’m really excited to welcome, Dr. Lembke, to the Healing Pain Podcast.
Thanks for having me.
I heard you first in MPR and I’ve listened to a couple of different other interviews. I love the book, I love the concept of the book. Of course, my platform being a doctor of physical therapy, pain is the first thing that we treat. We are now confronted by this wave of chronic pain as well as this opioid epidemic that, I think, we’re moving in the right direction, but it can sometimes be controversial and a little sticky for both patients and practitioners. If we could start with maybe a bit of a history lesson as to how did we get where we are today as far as opioids go. What transpired in our greater healthcare system as well as our nation?
It’s important to understand that the current opioid epidemic is, first and foremost, an epidemic of over-prescribing. Prior to 1980, doctors were very reluctant to prescribe opioids except for patients in extremes or at the very end of life. But in 1980, there was a shift to prescribe opioids more liberally for minor pain and chronic pain conditions.
What started out as good intentions unfortunately morphed into what has become a scourge in this nation with hundreds of thousands of people dying due to opioids. In many cases, those opioids were received directly or indirectly from a doctor’s prescription. In order to understand how we got from good intentions to the opioid epidemic, one of the things that I like to remind people of is that, yes, Big Pharma played a role, no doubt about it. Pill mill doctors woefully exchanging prescriptions for cash are out there. This is an epidemic that is driven not just by nefarious doctors and greedy pharmaceutical companies. This is an epidemic that was made possible because of fundamental changes in our healthcare delivery system beginning about three decades ago.
Just to briefly summarize some of those changes, one of the biggest is there was a huge migration out of private practice into large, centralized, industrialized healthcare systems. When this happened, there was tremendous pressure on physicians to palliate pain, to get patients in and out quickly, to prescribe pills and perform procedures because that’s what pays, and ultimately to please patient customers. Patients morphed very quickly from being people who are sick and need a healer, to being customers who we need to get as much money from as humanly possible. This was and continuous to be a huge contributor to the current opioid epidemic, as well as other causes and shifts in the way medicine is now delivered.
It’s a wonderful way to start the podcast. I appreciate the introduction. You mentioned, this has gone back now two to three decades. How much do you think the WHO, World Health Organization’s opioid ladder had to really do with, one, how we view opioids and their place in the management of pain? Then two, how prescribers really should utilize their prescription pads in treating those with chronic pain?
I will say that the World Health Organization is shifting dramatically on this issue. There were essentially four myths propagated about opioids, beginning in the early 1980s. The first myth was that opioids are effective treatment for chronic pain. We know today that that is probably not true for the vast majority of patients, mainly because people build up tolerance and they stop working and then all you’re left is with side effects and the withdrawal when you don’t take them. That was a huge myth. We do know, by the way, it’s always important to emphasize this, that opioids are great for acute pain when taken for very short durations.
The other major myth was that as long as a doctor’s prescribing opioids for a medical condition, the risk of getting addicted is less than 1%. We now know that’s not true. Even if you’re a patient with no history of addiction, who’s taking the medications as prescribed by a doctor for real pain caused by a real medical condition, there’s about a 30% risk of becoming addicted to those opioids. That risk increases the longer you take them and the higher the dose. Those were two of the major myths.
The third myth was that no dose is too high. If a patient has an initial good response to opioids for pain and then that response wears off, just keep going up and up and up. This really led to very poor care in this country. We now see on a regular basis, patients on astronomical doses of opioids who have been on those doses for decades, sometimes being delivered by an intrathecal pump.
The fourth myth was this myth around pseudoaddiction. Pseudoaddiction was a phrase that was coined essentially by the pharmaceutical industry to say that if you had a patient who is demonstrating behaviors that look the heck of a lot like addiction, that it was really pseudoaddiction and really they were just in pain and needed more opioids.
As I had been doing my podcast, I wrote my book about chronic pain, of course, I have a number of people who are wonderful and really backed me. But as you know, there’s always someone who comes to you and says, “You don’t know what it’s like to live with pain. You don’t have X disease. You’re telling me that I should not take this drug.” I think the first thing is chronic pain is always real, it’s not in your head, it’s actually a real disease. There are changes both in the body and the brain with chronic pain.
One of the things that I had been kind of professing, because I want to be very sensitive and compassionate to those with chronic pain, is that there are a place for opioids. What I’ve been starting to really profess more and more is that when we use them, they should be in the early form of the disease, in the lowest dose and for the shortest period of time, and typically only integrated with other natural strategies like mind-body behavior, like physical therapy, like nutrition, if you need that. What is your opinion and belief on that type of stance?
I agree with you 100%. Sometimes my message is misinterpreted as my saying that pain isn’t real, that people should suffer, and that’s absolutely not the case. I spend a lot of time with people with severe and debilitating pain and they really have my infinite compassion because I can’t even begin to imagine how hard their daily existence is. Pain is real and the suffering that people experience from chronic pain is absolutely real and tremendously sad. I do think there is a place for opioids in the treatment of even chronic pain, as long as they’re used intermittently to give the brain and the body enough time to reset, so that they remain effective.
Let me just say, I don’t have any dogmatic or righteous stance on opioids. If they work for chronic pain, I would be happy to pass them out myself. The reason that I speak out against their use is because generally they don’t work when taken daily over a long period of time because of this phenomenon of tolerance. I think for chronic pain patients who respond well to opioids, one potential way to use them is to give them in doses that might be taken for severe, unbearable, breakthrough pain, intermittently with enough case in between of no opioids that you don’t develop tolerance.
It’s a great point. You already mentioned the addiction, dependence. Your brain, your body becomes dependent on this. Can you talk for a moment about opioid-induced hyperalgesia because it’s important that people understand that. For some people, this work but for a lot of people, they actually make pain much worse.
We don’t fully understand the biological phenomenon behind opioid-induced hyperalgesia. But it has something to do with the tolerance phenomenon. Basically, I think what happens is that daily opioid use resets the pain threshold such that the individual is more sensitive to pain. The way that manifests clinically is individuals will come in and not only have worse pain in their original body location, but they may even talk about having pain in new places that they never had before. We do think that that is a function of the pain threshold resetting itself as a consequence of being on daily opioids.
It’s great information because part of what we do when we podcast and we talk about this is, is to give people the information they need. I had a good friend of mine contacted me a couple of weeks ago and said, “My dad went to his GP, his Internist for just back pain.” Her dad is a 64-year-old very healthy man that still works. The first thing that the GP did was prescribe an opioid for him. She called me and said, “Should he take this?” I said, “Honestly, in my medical opinion, if your father just developed back pain a couple of weeks ago, has no other medical problems, and does not have a chronic disease, then no.” There are a lot of other strategies and medications. In fact, if you’re going to go to the medication group, we know that back pain can be treated from a mind-body perspective, that should be first.
It brings me to my next point. In the subtitle of your book, you talk about doctors being duped. It’s a little controversial. Even the title of your book, Drug Dealer MD, sounds a little controversial. My question is, what has been the response from your immediate colleagues to your book and then maybe the colleagues that are in your perimeter who can contact you via email, but you have no real connection with them? We know that when people sit behind emails, sometimes their true thoughts come to light and they’re a little bit less sensitive about what they say.
Even though my book is called Drug Dealer MD, it’s actually a book that’s really trying to unravel how it is that very good people, who have gone into medicine to save lives and alleviate suffering, end up being the same people who are harming patients by over prescribing. What I essentially conclude is that well-intentioned physicians are caught in a healthcare system that makes it very difficult for them to be healers because they have little time, because they get paid to prescribe, because the insurance company will not, oftentimes, as you know well, pay for non-opioid alternatives for pain, whether it’s physical therapy or Trigger Point massage or psychotherapy or acupuncture. It’s very hard to find the people to do that work. It’s hard to get the insurance company to pay for it. But any primary care doctor can, within a minute, write you a prescription for Vicodin. That’s a really unfortunate reality that by the way continues despite intense media coverage.
What’s been the response to my book? One of the most gratifying things about the response to my book has been the overwhelmingly positive response from physicians who read the book and really experience a catharsis. I just got an email yesterday from an anesthesiologist who treated pain for years. He said to me, “I’m so grateful for your book. I eventually had to leave the profession because I was so discouraged. I will wake up every day and wonder if I was harming people or helping them. Finally, I concluded I wasn’t able to help them and I left the business.” Not only is the opioid epidemic a tragedy for patients who’ve become addicted or otherwise harmed by opioids. It’s really a tragedy for physicians who are unable to practice today in a way that resonates for them as competent healers.
The type of practice you’re talking about is what is termed as the biomedical model. That’s the model where we treat pain with drugs, surgery and injections. As we move toward a biopsychosocial model, which are some of the things that we’re talking about today and the things I talk about in my podcast, how do you see a physician’s practice changing to fit into that model? Or do we have to run, in essence, two types of practices side by side, so to speak?
It is entrenched, the biomedical model, but I’m hopeful that we can make a change. I think if we don’t make a change, we’re going to lose customers eventually. At some point, people aren’t going to look to the medical profession as it’s currently set up as a place where healing occurs. They’re going to go outside and they’re going to find alternative people who put out their shingle but offer something that really helps them get better. If we don’t change what we’re doing, we’re not going to have much of a stake in the ground. In order though to really make the change, we can educate and we can admonish and we can encourage. But until there are financial incentives for physicians to practice differently, we will not see a change in the way that healthcare is delivered.
We have to change the reimbursement structure so that doctors are actually incentivized not to prescribe pills. That they’re incentivized to get patients off of opioids because it’s an incredibly labor intensive long process. Until we’re doing that, I don’t think we’re going to make much headway. In terms of how that might that look, I think ultimately we’re going to work in larger teams. There will be a physician as part of that team but we’re going to have much more input from physical therapists, nurse practitioners, all kinds of healers from non-western traditions. That’s probably the model that’s ultimately going to work. I talked about that in my book, a sort of community model that also uses peer recovery as part of the healing mechanism.
The aspect of peer recovery is huge. I practice it in my clinic. I do group sessions, as well as I have an online program where I try to get people to interact with each other, which is really powerful. You talk about illness as in identity in your book. When we’re talking about chronic pain especially, it’s important to review that concept with people and what that means, and how someone can start to be mindful and maybe pause and look at their own life and their own chronic disease or chronic pain and how it relates to that concept as illness as an identity.
What I’m seeing more and more of is people with identity crisis more generally. That’s across the board in my psychiatric practice. That’s one of the major dilemmas of the modern era, that we don’t know who we are or who our community is, who’s our tribe? What has emerged is that being an ill person and having a certain type of disease is one way to create identity. We see that all the time in online groups, patient advocacy forums, many of those funded by the pharmaceutical industry. There’s an interesting interrelationship there. I’m not, in principle, necessarily opposed to illness as identity as long as it goes along with an adaptive illness narrative. By that I mean essentially a recovery narrative. If you’re going to identify yourself as someone who has a certain illness and join together with others who have an illness, then let it be in the recovery model where you tap into your strength and resilience in ways which you live in the world despite your illness.
What I see a lot of is a kind of a codependent defeatist narrative. These would be healthcare system patients who show up and say, “I’m sick. You’re the doctor. You need to fix me. Why haven’t you done it yet?” That is disastrous for patients, because no matter what we do they’re not going to get better. The other thing I talk about in my book is disability and the way that being a patient has become a way to pay the bills. That then further incentivizes this defeatist, helpless and codependent narrative, which I think is really doing a great injustice to the very patients who have adopted an illness identity.
It also makes me think about the identity that we have as practitioners who are still functioning in really an outdated model. Two things come to mind. One is I think there are many physicians that will start to change their practice, but they’re going to say, “This not really what I went to school for. I saw myself as prescribing medications, doing procedures, versus maybe coaching people on the lifestyle strategies they can do to heal themselves naturally.” I’ve even seen it in my own profession in physical therapy where physical therapists have even said to me, “You talk about this biopsychosocial approach. I went to school and I thought I’d be working with muscles and joints and bones. Now, I feel like I have to implement principles of psychology into practice.”
Pain psychology has a definite place when you work with people with chronic pain. A lot of what we do as physical therapists has a cognitive behavioral aspect to it if you’re doing the therapy right for the person with chronic pain. Can you talk about our own identity as clinicians as we move away from this outdated model towards a model that really can heal people?
I think that’s why the team based model is going to be so important. One of the great things about healthcare from a professional point of view is you can have all different personality types find their niche. People who go into surgery or in the example you give, a physical therapist who goes into physical therapy because they’re excited to work with muscles. There will be somebody who is not going to be excited to be talking about biopsychosocial perspectives on recovery. Some of them might. It might be like an open door for them, “I love that, that’s great.” But others might just find it not for them.
Certainly, surgeons by and large are people who really are fascinated by the body and fixing it up on a mechanical level. Many of them really don’t want to engage with the patients otherwise. That’s a horrible generalization for all those surgeons out there. There are obviously many of you who love that part. I talk to a lot of surgeons, they’re like, “I didn’t go into psychiatry because I’m not interested in that part of it.” I think you know you can’t force a square peg into a round hole. But if we work together in a team that actually speaks to each other about a given patient, then what we can do is optimize each of our individual talents to help a given patient to get better.
As someone who’s written a book, and it’s called Drug Dealer MD, it’s a wonderful book. I recommend everyone go out there and get it and read it, whether you’re a practitioner or whether you’re someone who’s struggling with an addiction. How does a physician who’s probably prescribing medications start to explain to a patient who has had chronic pain for decades and has been on these medications that, one, this doesn’t work for them, it doesn’t work for chronic pain. Then two, we need to start to take some steps to wean you off of it.
What I do a lot of is mea culpa, just transparently talking about how, “Twenty years ago, we thought very differently about this medication in the treatment of chronic pain. We prescribed it like it was going out of style. Now we know better. Here are the things that we have learned.” I try to go through all of the risks associating with chronic opioid therapy and especially highlighting those risks that that individual patient is experiencing, whether it’s severe constipation, cognitive deficits, depression, opioid-induced hyperalgesia or even frankly, tolerance. I now include tolerance as a risk associated with opioids because tolerance means it’s not working for you. But now if we try to take you off, you’re going to experience withdrawal, which means that essentially we can’t use this medication anymore. We have to get you off of it.
The other thing that I tend to do is I introduce the concept of addiction very early and I normalize it. I’ll say to patients, “The other thing we might discover as we try to get you off of it is that it’s extremely difficult for you. That just might me because you’re in this subtype of people who are extremely dependent and will have to taper very slowly. But it’s also a possibility that you’ve become addicted to the medication.” I think it’s important to normalize by saying, “You’re not alone. There are more than two million people in this country have become addicted to opioids. The vast majority through a doctor’s prescription initially. The good news is there’s treatment for opioid addiction and it’s good treatment. We can get you that treatment if we discover that that’s a problem.” That’s a very nice way to set it up because then that strives to deshame it, because there’s so much shame for people around having gotten addicted.
This may be a similar question and maybe a similar response, but since we’re talking about addiction, what needs to change in our country to help people that struggle with addiction? Because ultimately, pain is one thing, and we’re talking about healing chronic pain, but we have this other issue here as well that we really can’t ignore.
First and foremost, we in our society as healthcare professionals have to really embrace this idea of addiction as a disease. What I tell to many physicianal audience is you have to think of addiction as a disease even if you don’t really believe it is one. Because if you continue to operate in your practice as if addiction is not a disease but a problem of the will, then you’re going to just perpetuate the prescription opioid crisis. As long as you’re putting it on your problem list and addressing it and doing something about it, there’s a hope that we can begin to stem the tide. We need to embrace addiction as a disease.
Then very importantly, a recurring theme here, we need to get insurance companies to pay for treatment. Often I’ll hear people say, “Aren’t most addicts in denial? That’s why they don’t go and get treatments.” I’m like, “No.” Most of the time what I see is people who know they’re addicted, who want treatment and who either can’t pay for it or can’t find it or both. Right now, most of addiction treatment is siloed outside the house of medicine.
What you don’t have is an opportunity to walk into your primary care doctor’s office and say, “I’ve got some problems with my hypertension. My glucose is a little off and by the way, I’m addicted. Would you help me out with that?” If you do, your primary care doctor would be like, “What? I don’t know anything about that. I don’t have the first idea,” because we don’t train doctors. From the ground up, on the first day of medical school all the way through residency, we need to train doctors how to screen, detect it. They don’t have to know how to treat it, but they know how to refer when they do get treatment. We have to create an infrastructure to provide that treatment and pay doctors to do that treatment.
It also makes me think, how has your book started swinging the pendulum in the opposite direction for your specific profession, for psychiatry, which a century ago doesn’t have medication, then moved dramatically in the direction of medication treatment? Now, will they be moving away from it? What’s interesting about that is at one point they used to use more cognitive behavioral strategies and have taken that out, and really that’s now in the hands of a psychologists. It’s an interesting paradigm shift that is happening in your profession specifically.
My book is not just about overprescribing of opioids, it’s also about overprescribing benzodiazepines, like Xanax and Valium, overprescribing of stimulants like Adderall and Ritalin. These are huge problems and there are really hidden epidemics. You won’t read much in the paper about this. Benzodiazepine prescribing has also quadrupled since 1999. Stimulant prescribing is tenfold what it was in the early 1990s with increasing number of prescriptions in younger children, children as young as age two, which I personally find horrific.
Absolutely, this is fundamental, not just for people who prescribe opioids but for people who prescribe any potentially addictive drug. What I think is so interesting about the psychiatric profession and the pain profession is how much they’ve gone in parallel. Prior to let’s say 1950, you’re absolutely right, psychiatry was top therapy. If you were a psychiatrist, you learned psychoanalysis. Today, if you’re a psychiatrist, you learn how to deal drugs. The same thing happened with pain in the early 1980s. Prior to 1980, it was the multi-model approach. People did massage, they did therapy. They did acupuncture. Everybody knew that’s what you had to do. Then we forgot. If you talk to old timers in pain, they’ll tell you, “We’re just reinventing the wheel here, that’s what we were doing before opioids came along.”
It’s really true. As a physical therapist, there are many physical therapists that are now educating both the public and other practitioners about something called Pain Science. It’s educating people, no matter who we’re talking about, about what pain really is and how chronic pain differs from acute pain. Acute pain typically is about an actual physical injury. We know that chronic pain is typically something that begins about three months after an injury and is really a problem with the nervous system. In fact, you don’t even need to have an injury to have chronic pain develop. We see that with people who have PTSD, we see that with people with early childhood trauma, fibromyalgia and many types of diseases and conditions. How would a physical therapist approach, let’s say, the traditional psychiatrist and say, “I’d like to talk to you about some of the new happenings in Pain Science and how I can help you heal your patients better.”
That’s a great question. I don’t know the answer to that. I’m very fascinated by the phenomenon that you described, which is this manifestation of chronic pain syndromes in the absence of any obvious disease or organic pathology that anybody can detect. I have my own speculations on what that’s about, why we’re seeing rising numbers of otherwise healthy young people coming in with pain from the tips of their eyelashes to the tips of their toes and everywhere in between. It’s a fascinating phenomenon. I think it’s one that we do need to look at and figure out. I haven’t figured it out yet and so I wouldn’t really know much about how to advise others, but I’d be curious to hear your thoughts.
My thoughts are, I think at first, it’s really a grassroots effort. It’s educating yourself first, because there are still many practitioners who don’t understand what chronic pain is. Second, I think learning how to explain it to a patient is really enormous. Because most of the patients who come into a physical therapy practice have a lot of preconceived notions about what pain is. Psychologists see this as well. It takes a long time for a physical therapist to really break down what pain is to a patient and how the pain they’re feeling, actually on many levels, probably isn’t related to some kind of damage in their joints. Pain is a large spectrum, so if we’re talking about someone with osteoarthritis, then it maybe that the damage we see in your joint is related to your pain.
But there are also other emotional triggers that are related to your pain. It’s your cognition about pain. It’s what you’ve been taught about pain. It’s what your cultural and social beliefs are about pain. It’s a deep topic that there probably should be a PhD just in Pain Science education. I think that’s starting. I think opening the lines of communication, like we’re doing today, between practitioners. They probably wouldn’t normally talk. I can tell you in my 22 years of practice, I’ve had psychiatrists as patients, many of them. But I’ve had very few that have actually referred patients to physical therapy. Typically because they’re prescribing medication, so it’s wonderful chatting with you today. Can you tell people how they can learn more about you and your book? I would love everyone to have an opportunity to access it and buy it, of course, and learn more about you.
My book is available on Amazon and I think at Barnes and Nobles and other bookstores near you. I’m not a social media person. One of my self-care measures is trying to preserve my limited sanity by not being on those social media, because I think my head would explode. There’s not a lot of places that you can learn about me. Right here on your show, Joe, that’s where you can learn about me.
I think it’s great. I’m really happy to have you on the podcast today, Dr. Lembke. If you’re interested in her book, it’s called Drug Dealer MD: How Doctors Were Duped, Patients Were Hooked, and Why It’s So Hard to Stop. You can find it in any bookstore and, of course, online at Amazon or other retail book dealers. She is a physician at Stanford University, so you can find her there as well. I want to thank her for being on the Healing Pain Podcast. Make sure to stay tuned each week at www.DrJoeTatta.com to my website, as well as the Healing Pain Podcast where we talk about natural strategies for healing chronic pain for both the practitioner and the patients. Thank you very much and I’ll see you next week.
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