The Prescription Pain Pill Epidemic: A Conversation with Dr. Anna Lembke

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My colleague, Dr. Anna Lembke is the Program Director for the Stanford University Addiction Medicine Fellowship, and Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. She is the author of a newly released book on the prescription pain pill epidemic: “Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop” (Johns Hopkins University Press, October 2016).

I spoke with her recently about the scope of this public health tragedy, how we got here and what we need to do about it.

Dr. Jain: About 15-20 years ago American medicine underwent a radical cultural shift in its attitude towards pain, a shift that ultimately culminated in a public health tragedy. Can you comment on factors that contributed to that shift occurring in the first place?
Dr. Lembke: Sure. So the first thing that happened (and it was really more like the early 1980’s when this shift occurred) was that there were more people with daily pain. Overall, our population is getting healthier, but we also have more people with more pain conditions. No one really knows exactly the reason for that, but it probably involves people living longer with chronic illnesses, and more people getting surgical interventions for all types of condition. Any time you cut into the body, you cut across the nerves and you create the potential for some kind of neuropathic pain problem.
The other thing that happened in the 1980’s was the beginning of the hospice movement. This movement helped people at the very end of life (the last month to weeks to days of their lives) to transition to death in a more humane and peaceful way. There was growing recognition that we weren’t doing enough for people at the end of life. As part of this movement, many doctors began advocating for using opioids more liberally at the end of life.
There was also a broader cultural shift regarding the meaning of pain. Prior to 1900 people viewed pain as having positive value: “what does not kill you makes you stronger” or “after darkness comes the dawn”. There were spiritual and biblical connotations and positive meaning in enduring suffering. What arose, through the 20th century, was this idea that pain is actually something that you need to avoid because pain itself can lead to a psychic scar that contributes to future pain. Today, not only is pain painful, but pain begets future pain. By the 1990’s, pain was viewed as a very bad thing and something that had to be eliminated at all cost.
Growing numbers of people experiencing chronic pain, the influence of the hospice movement, and a shifting paradigm about the meaning and consequences of experiencing pain, led to increased pressures within medicine for doctors to prescribe more opioids. This shift was a departure from prior practice, when doctors were loathe to prescribe opioids, for fear of creating addiction, except in cases of severe trauma, cases involving surgery, or cases of the very end of life.
Dr. Jain: The American Pain Society had introduced “pain as the 5th vital sign,” a term which suggested physicians, who were not taking their patients’ pain seriously, were being neglectful. What are your thoughts about this term?
Dr. Lembke: “Pain is the 5th vital sign” is a slogan. It’s kind of an advertising campaign. We use slogans all the time in medicine, many times to good effect, to raise awareness both inside and outside the profession about a variety of medical issues. The reason that “pain is the 5th vital sign” went awry, however, has to do with the ways in which professional medical societies, like the American Pain Society, and so-called “academic thought leaders”, began to collaborate and cooperate with the pharmaceutical industry. That’s where “pain is the 5th vital sign” went from being an awareness campaign to being a brand for a product, namely prescription opioids.
So the good intentions in the early 1980’s turned into something really quite nefarious when it came to the way that we started treating patients. To really understand what happened, you have to understand the ways in which the pharmaceutical industry, particularly the makers of opioid analgesics, covertly collaborated with various institutions within what I’ll call Big Medicine, in order to promote opioid prescribing.
Dr. Jain: So by Big Medicine what do you mean?
Dr. Lembke: I mean the Federation of State Medical Boards, The Joint Commission (JACHO), pain societies, academic thought leaders, and the Food and Drug Administration (FDA). These are the leading organizations within medicine whose job it is to guide and regulate medicine. None of these are pharmaceutical companies per se, but what happened around opioid pain pills was that Big Pharma infiltrated these various organizations in order to use false evidence to encourage physicians to prescribe more opioids. They used a Trojan Horse approach.. They didn’t come out and say we want you to prescribe more opioids because we’re Big Pharma and we want to make more money, instead what they said was we want you to prescribe more opioids because that’s what the scientific evidence supports.
The story of how they did that is really fascinating. Let’s take The Joint Commission (JACHO) as an example. In 1996, when oxycontin was introduced to the market, JACHO launched a nationwide pain management educational program where they sold educational materials to hospitals, which they acquired for free from Purdue Pharma. These materials included statements which we now know to be patently false. JACHO sold the Purdue Pharma videos and literature on pain to hospitals.
These educational materials perpetuated four myths about opioid prescribing. The first myth was that opioids work for chronic pain. We have no evidence to support that. The second was that no dose is too high. So if your patient responds to opioids initially and then develops tolerance, just keep going up. And that’s how we got patients on astronomical amounts of opioids. The third myth was about pseudo addiction. If you have a patient who appears to be demonstrating drug seeking behavior, they’re not addicted. They just need more pain meds. The fourth and most insidious myth was that there is a halo effect when opioids are prescribed by a doctor, that is, they’re not addictive as long as they’re being used to treat pain.
So getting back to JACHO, not only did they use material propagating myths about the use of opioids to treat pain, but they also did something that was very insidious and, ultimately, very bad for patients. They made pain a “quality measure”. By The Joint Commission’s own definition of a quality measure, it must be something that you can count. So what they did was they created this visual analog scale, also known as the “pain scale”. The scale consists of numbers from one to ten describing pain, with sad and happy faces to match. JAHCO told doctors they needed to use this pain scale in order to assess a patients’ pain. What we know today is that this pain scale has not led to improved treatment or functional outcomes for patients with pain. The only thing that it has been correlated with is increased opioid prescribing.
This sort of stealth maneuver by Big Pharma to use false evidence or pseudo-science to infiltrate academic medicine, regulatory agencies, and academic societies in order to promote more opioid prescribing: that’s an enduring theme throughout any analysis of this epidemic.
Dr. Jain: Can you comment specifically on the breadth and depth of the opioid epidemic in the US? What were the key factors involved?
Dr. Lembke: Drug overdose is now the leading cause of accidental death in this country, exceeding death due to motor vehicle accidents or firearms. Driving this statistic is opioid deaths and driving opioid deaths is opioid pain prescription deaths, which in turn correlates with excessive opioid prescribing. There are more than 16,000 deaths per year due to prescription opioid overdoses.
What’s really important to understand is that an opioid overdose is not a suicide attempt. The vast majority of these people are not trying to kill themselves, and many of them are not even taking the medication in excess. They’re often taking it as prescribed, but over time are developing a low grade hypoxia. They may get a minor cold, let’s say a pneumonia, then they’ll take the pills and they’ll fall asleep and won’t wake up again because their tolerance to the euphorigenic and pain effects of the opioids is very robust, but their tolerance to the respiratory suppressant effect doesn’t keep pace with that. You can feel like you need to take more in order to eliminate the pain, but at the same time the opioid is suppressing your respiratory drive, so you eventually become hypoxemic and can’t breathe anymore and just fall into a gradual sleep that way.
There are more than two million people today who are addicted to prescription opioids. So not only is there this horrible risk of accidental death, but there’s obviously the risk of addiction. We also have heroin overdose deaths and heroin addiction on the rise, most likely on the coattails of the prescription opioids epidemic, driven largely by young people who don’t have reservations about switching from pills to heroin..
Dr. Jain: I was curious about meds like oxycontin, vicodin, and percocet. Are they somehow more addictive than other opioid pills?
Dr. Lembke: All opioids are addictive, especially if you’re dealing with an opioid naive person. But it is certainly true that some of the opioids are more addictive than others because of pharmacology. Let’s consider oxycontin. The major ingredient in oxycontin is oxycodone. Oxycodone is a very potent synthetic opioid. When Purdue formulated it into oxycontin, what they wanted to create was a twice daily pain medication for cancer patients. So they put this hard shell on a huge 12 hours worth of oxycodone. That hard shell was intended to release oxycodone slowly over the course of the day. But what people discovered is that if they chewed the oxycontin and broke that hard shell, then they got a whole day’s worth of very potent oxycodone at once. With that came the typical rush that people who are addicted to opioids describe, as well as this long and powerful and sustained high. So that is why oxycontin was really at the center of the prescription opioid epidemic. It basically was more addictive because of the quantity and potency once that hard shell was cracked.
Dr. Jain: So has the epidemic plateaued? And if so, why?
Dr. Lembke: The last year for which we have CDC data is 2014, when there were more prescription opioid-related deaths, and more opioid prescriptions written by doctors, than in any year prior. This is remarkable when you think that by 2014, there was already wide-spread awareness of the problem. Yet doctors were not changing their prescribing habits, and patients were dying in record numbers.
I’m really looking forward to the next round of CDC data to come out and tell us what 2015 looked like. I do not believe we have reached the end or even the waning days of this epidemic. Doctors continue to write over 250 million opioid prescriptions annually, a mere fraction of what was written three decades ago.
Also, the millions of people who have been taking opioids for years are not easily weaned from opioids.. They now have neuroadaptive changes in their brains which are very hard to undo. I can tell you from clinical experience that even when I see patients motivated to get off of their prescription opioids, it can take weeks, months, and even years to make that happen.
So I don’t think that the epidemic has plateaued, and this is one of the major points that I try to make in my book. The prescription drug epidemic is the canary in the coal mine. It speaks to deeper problems within medicine. Doctors get reimbursed for prescribing a pill or doing a procedure, but not for talking to our patients and educating them. That’s a problem. The turmoil in the insurance system we can’t even establish long term relationships with our patients. So as a proxy for real healing and attachment, we prescribe opioids. ! Those kinds of endemic issues within medicine have not changed, and until they do, I believe this prescription drug problem will continue unabated.

4 thoughts on “The Prescription Pain Pill Epidemic: A Conversation with Dr. Anna Lembke”

  1. Dr Jain makes a number of interesting quantitative statements about hard to estimate accurately situations. For instance,There are more than 16,000 deaths per year due to prescription opioid overdoses.”
    Further there are many comparative claims such as a social shift in the attitude towards pain management. She may be correct but those who make assertions have the responsibility of demonstrating the data relied on and the bases of the inference. Perhaps this was considered too academic for an informal exchange. But simple unsupported claims about important matters breeds sceptics .It is an advocates persuasive duty to get beyond such claims to definite references.

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  2. Was this interview recorded before December of 2016? As of this reading (March, 2017) there have been 3 reports from CDC since December of 2016, and they tend to show a decline in deaths that county coroners (which is what CDC relies on) attribute to “natural and semisynthetic opioids”. This would be the category that includes potentially prescribed drugs such as hydrocodone and oxycodone.

    It can take some adding and subtracting to make sense of some aspects of these recent CDC reports, because the typical CDC report does not use mutually exclusive categories. Thus if someone dies and the coroner finds (illicit) fentanyl, and a trace of hydrocodone in the same person, that counts as 1 point for “synthetic opioid” (the thing that actually killed the person) and 1 point for “natural and semisynthetic” (the thing that probably didn’t).

    However, if one looks at the trend lines (here is a tweet that shows them: https://twitter.com/StefanKertesz/status/840417218047422465) there has been a decline in the role of what we might call “potentially prescribed” opioids (often not prescribed to the person who dies with them in their system). The interview above seems not to include that information.

    There has been an increasingly dominant role of fentanyl (mostly illicit, not prescribed, according to CDC reports) and heroin. In my county, whose data I described in an article in the journal Substance Abuse, deaths attributable to the potentially prescribed opioids are in steep decline. This is evident in those few counties in the US where the coroners spend the extra money and order the send-out test for fentanyl, and that is the case in a county like my own (here is a Tweet showing the trend: https://twitter.com/StefanKertesz/status/840397135531134976)

    I think the narrative of egregious prescribing spurred by a toxic mix of failures (doctors who are afraid to say no, manipulative marketing by Pharma) is a clear profile of myriad failures at every level. Dr. Lembke describes those things well. I share her outrage.

    But what I see is a changing epidemic. Both stats and reports from many addiction colleagues across the country show that we are in a new and shifting phase to the opioid crisis.

    The prescription opioids are in decline when we look at overdose deaths.

    And in the ongoing reversal in prescribing, a kind of “we won’t get fooled again” reversal, many of my colleagues and I — addiction professionals, mostly— are quite worried about what is happening to patients who are being harmed, as doctors embrace an entirely reactive policy of cutting off opioids “left and right” (as my nurse puts it) to prove their bona fides.

    Whether patients survive that procedure has become a secondary matter. If a patient falls apart, is hospitalized, or dies in jail, or takes to the illicit market and dies, it is not not recorded or observed, although those stories come to my attention and some of them are making it into social media (even JAMA in one case).

    But it’s the de-prioritization of the patient’s actual outcome that worries me. If an involuntarily tapered patient leaves the office and dies at home or elsewhere, that simply means they are out of the denominator for the next quality metric, which is typically based on dose. That is actually is a good thing if one’s goal is to make the metric look good. It’s kind of bad if the goal is a living, functioning patient.

    I have had to pick up the pieces of people injured in this turnaround. What’s being done to some opioid-treated patient patients is not what the CDC Guideline advised.

    I am concerned. I know a good number of academic colleagues are concerned because they signed a letter to CMS. I would love to see this discussion continue and evolve to include changing patterns in how patients are treated. http://www.politico.com/story/2017/03/docs-warn-that-medicare-crackdown-will-hurt-pain-patients-235917

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  3. I think that the reasons behind the opioid epidemic are widespread, and simplifying the problem to pharmaceutical company’s advertisement strategies or physician’s prescribing patterns misses a lot of other issues. Society in general has been trending towards instant gratification, which puts a lot of pressure on doctors to find quick ways of treating pain. Many pain therapy options take time, whereas opiates are known to work quickly and to be effective. What one physician may have prescribed as a short term treatment strategy, another might adopt as long-term depending on how the patient presents their pain. Now that’s not to say there are not physicians who prescribe opiates inappropriately, because there absolutely are. The issue is just a little bit more complicated than that. For every prescription written a pharmacist will have to verify and dispense the medication. Does the pharmacist always check the PDMP? Do they always call the physician if they are concerned about someone’s pain management? No they don’t. If healthcare professionals continue to work together more effectively, it would be possible to increase the responsible prescribing of opioid pain medications.

    Other issues that factor into the epidemic aside from prescribing and filling patterns are insurance company coverage and lack of accessible information. First line treatment for chronic pain is supposed to include physical therapy, which is where the insurance issue comes into play. Many people are covered by insurance plans that pay for a very minimal amount of physical therapy, and many patients do not have the means to pay for continuous therapy out of pocket. Then comes the lack of accessible information. A huge contributing factor to opioid overdose is concurrent use of benzodiazepines. This should not be an issue assuming that the patient uses one doctor for their medications and one pharmacy to fill their prescriptions, however, this is often not the case. When physicians are unaware that their patients are receiving a benzodiazepine from another doctor, they may not realize how dangerous their pain medication choice is for the patient. Then if the patient does not fill both medications at the same pharmacy, the pharmacist cannot catch the drug interaction, compounding the problem.

    Hopefully recent reports about the opioid epidemic will help to address some of the prescribing issues, but there are other contributing factors and they all need to be addressed in order to improve patient care and the overall management of pain.

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