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Stanford’s Lembke: Most high-dose opioid patients should be tapered down—even involuntarily.
By ROGER PARLOFF|May 29, 2018
Addiction psychiatrist and Stanford medical school professor Anna Lembke at a TEDx talk in May 2017.
Quick Takeaway
  • “The box we got ourselves into here is equating opioid prescribing with compassion."
  • Risks of high-dose opioid therapy include overdose death, addiction, and increased pain.
  • She argues that most high-dose patients should be tapered down—even involuntarily.
  • She urges "deprescribing clinics” to support patients’ physical and psychological pain during the taper.

When Anna Lembke first became a psychiatrist, addiction was an area she avoided. “I didn’t consider it a disease,” she recounts, “and I didn’t want to treat those patients. But what I realized eventually was that I was actually harming my patients by ignoring their substance use problems. Once I could help them with those, their other psychiatric problems got better.”

Lembke was born in Arizona in 1967 to German immigrants—both doctors. She grew up mainly in Evanston, Ill., graduated from Yale College in 1989 (summa cum laude), and from Stanford University School of Medicine in 1995. She is a practicing addiction psychiatrist and an associate professor of psychiatry at Stanford, where she is also chief of the school’s Addiction Medicine Dual Diagnosis Clinic.

In 2016 she published Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop (Johns Hopkins University Press), an influential book about the origins of the opioid epidemic, including the institutional pressures on doctors to overprescribe.

This past February she published articles on the overprescription of benzodiazepines (drugs like Ativan, Klonopin, Valium, and Xanax) in the New England Journal of Medicine and STAT. She is now concerned, she says, with still another “silent epidemic”: “the ten-fold increase in stimulant prescribing” since the 1990s—drugs like Adderall, Concerta, Ritalin, and Vyvanse—including to “ever younger age cohorts.”

The following is an edited excerpt from an interview she gave Opioid Watch earlier this month, focusing on another current focus of hers: How to treat chronic pain patients who are currently on high-dosage opioid therapy.

Many people are saying that opioid prescribing has been coming down since about 2010 or 2012, and now the pendulum has swung too far. That it’s getting too hard for chronic pain patients to get the opioids they need for pain that won’t respond to anything else.

Opioid prescribing in this country has come down by about 20 percent from its peak, according to the CDC, and maybe as much as 29 percent as of last year, according to the latest private figures.  However if you look at the CDC data, there are still many counties in this country where opioid prescribing has not decreased and has, in fact, continued to go up since 2010.

We’re still prescribing three times as much as we did in the 1990s, four times as much as any country in Europe and more than ten times as much as in Japan. And the reason that those are apt comparisons is that those are other developed, rich nations with aging populations and comparable need for analgesia.

Addiction psychiatrist and Stanford medical school professor Anna Lembke.

So we’re still way out of line with the rest of the world. And way out of line for the overall need for analgesia.

Is there inadvertent harm caused by this decrease in prescribing? Absolutely. Mainly the people that are harmed are the people that have developed iatrogenic [i.e., caused by medical treatment] opioid dependence or addiction and who now find themselves unable to get the same quantities that they were getting previously.

Some of those people are turning to illicit sources of opioids, including heroin, and, of course, once you turn to illicit sources, especially if you’re ingesting the highly potent fentanyl without knowing it, you’re at high risk.

Other people are experiencing a lot of psychological and physical distress because they’re having to taper too rapidly or stop their opioids abruptly because they have a prescriber who suddenly says, “I’m not going to prescribe for you anymore.” I’ve treated many patients who are able to get off of chronic opioid therapy, as long as the taper is slow enough, but are unable to do it with a rapid taper or abrupt discontinuation.

So is that a good thing? Absolutely not. In the past half decade, we’ve paid a lot of attention to how to help people who are obviously addicted. We’ve got all kinds of grants to support various forms of medication-assisted treatment for addiction, etc.

What should be done for them? First of all, we have to give them non-opioid alternative treatments for their pain. And that means robust physical therapy, psychotherapy, mind-body work, massage, you name it.

What we haven’t paid attention to at all, though, is this large cohort of individuals with chronic pain who are dependent on high-dose opioids, who don’t actually meet the criteria for addiction—because they only ever took their medication as prescribed by a doctor—and now are being told: You have to cut back.

At the same time, we have to taper them down and potentially off of opioids, or at least to safer doses, but we have to do it in a safe and compassionate way.

What should be done for them? First of all, we have to give them non-opioid alternative treatments for their pain. And that means robust physical therapy, psychotherapy, mind-body work, massage, you name it.

At the same time, we have to taper them down and potentially off of opioids, or at least to safer doses, but we have to do it in a safe and compassionate way.

Many people on high-dose opioids and benzodiazepines [drugs like Xanax, Klonopin, Ativan, and Valium] have significant psychiatric co-morbidity [i.e., mental issues besides the purely medical issues]. These people are vulnerable to mood episodes—depression and suicidality—anyway. And now we’re taking them down on a very potent, euphorogenic drug, and they’re becoming depressed.  They feel misunderstood, mistreated. In some ways they’re absolutely right. They’re being abandoned by the medical system. We need to provide adequate psychological and psychiatric support, along with non-opioid pain treatment, for chronic pain patients who are tapering off of high dose opioids.

I advocate for specialty deprescribing clinics where we can send these patients, and/or multidisciplinary care management teams embedded in primary care, which can support deprescribing. Deprescribing means tapering the patient slowly down or off a medication in a way that takes into account physical dependence, and provides the necessary support to address both their physical and psychological pain during the taper. [Lembke will be teaching a free online continuing medical education course called “Tapering Patients Off Chronic Opioid Therapy,” slated for release July 1.]

What are the dangers of not tapering down, and staying at high-dose levels? 

The big risks are addiction and accidental overdose death—“overdose” being somewhat of a misnomer, because many people die of opioids even when taken exactly as prescribed. This has to do with either the respiratory suppressant effects not being mitigated by tolerance, or because the opioids are being combined with other sedatives. Other side effects from chronic use include severe and potentially life-threatening constipation, depression, cognitive decline, hormone imbalance, cardiac problems, breathing problems, and increased pain—known as hyperalgesia.

The box we got ourselves into here is equating opioid prescribing with compassion. And that is a fallacy.

I have treated many patients who, once off of long-term opioids, report improvements in pain levels, cognitive function, and overall quality of life. It’s like they wake up again from a long sleep. They feel better, and their family members are grateful too. The box we got ourselves into here is equating opioid prescribing with compassion. And that is a fallacy.

What I try to teach is that opioid deprescribing is in many cases the most compassionate course you can take, even when your patient is reluctant to do it.

So should patients be tapered down against their will?

Unfortunately, yes in some cases. If we leave this decision entirely up to patients or their individual doctors, we will not turn the ship. We’ve done that experiment. It doesn’t work. The perverse incentives inside of medicine driving overprescribing on the physician side are overwhelming, and the subjective benefit of the opioid on the patient side are overwhelming, even in the face of obvious, objective harm to patients.

That’s just the way the molecule works. People lose the ability to accurately assess the impact. So I feel strongly that we need external measures to change these behaviors. Many of my patients are attempting a taper only because their doctor has said they would no longer prescribe for them. Without that, they would continue at those high and dangerous doses. These same patients do better and feel better on lower doses, and ultimately experience the same level of pain they did on the higher dose, once the body adjusts. Some of them get off of opioids altogether.

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You said we can’t leave this up to “patients or their individual doctors.”  I’m surprised to hear you say that we don’t even leave this up to the doctor. Who decides then?

Over 70 percent of physicians and other prescribers today work as salaried employees in large integrated health care systems. This is a huge change from 30 years ago when most physicians were self-employed. We are, in essence, factory workers. And the structure in which we work has a huge impact on how we practice medicine. It’s now protocolized. There are patient satisfaction surveys. At the end of every month I get a graphic showing me how much I’ve billed, and whether or not I’ve met my targets. This is a totally different beast we’re dealing with.

There are lots and lots of invisible and perverse incentives driving overprescribing on the physicians’ side. Given that fact—and I believe that’s a fact—you’re not going to get people to change their habits unless you disincentivize prescribing or give them incentives to provide non-opioid treatments, like paying more for physical therapy, psychoeducation, etc.

I really think the main reason doctors have reduced their opioid subscribing to date, has to do with public shaming in the media. Since the 1990’s, you couldn’t open a newspaper or turn on the TV without seeing some story about people dying because of doctors’ prescriptions. Until that kind of public shaming was greater than the shame a doctor experienced when she got a negative patient satisfaction survey response, we didn’t see any change in prescribing.

Just like everybody else on the planet, doctors respond to rewards and punishment. That’s what shapes behavior.

Same thing with patients. Many people have been absolutely outraged that Medicare has suggested that they would no longer pay for opioids above 90 morphine milligram equivalents per day. I think it’s a brilliant idea. I think it’s absolutely what we need. [“Morphine milligram equivalents”: Since different types of opioids—like oxycodone or hydrocodone—have different strengths compared to one another, physicians convert dosages to an equivalent dosage of morphine, so there will be a yardstick to measure them all against.]

You think Medicare should adopt a bright-line rule using that dosage figure?

Yes I do. They based it on the CDC guidelines, which in turn are based on data showing the higher the dose of opioids, and the longer patients are on them, the greater the risks. Medicare restrictions send the message to patients and doctors that if you’re going to exceed those limits, you’ll have to pay for the medication yourself. I think that is perfectly reasonable, as long as Medicare provides enough time, one-to-two years, for patients to be tapered slowly and compassionately down, and also supports and pays for non-opioid treatments for chronic pain.

Medicare has also said that it will provide an appeals process, whereby patients with severe chronic pain on high daily morphine-equivalent dosages, for whom the benefits outweigh the risks, could continue to get their medication covered. Now I do feel strongly that Medicare should have an appeals process whereby you can write to them say, “Hey, this person has been on 500 morphine milligram equivalents for three decades. I need more than six months to get them off. In fact, I probably need five years to get them off.”

One thing we know about addictive drugs is that users are very price sensitive. Whether you’re talking about heroin or Percocet prescribed by a doctor. When patients have to pay more, all of a sudden their internal calculus about whether or not it’s worth it changes, despite significant physical pain. In the last year I’ve had patients express motivation to get to a lower dose of opioids, because they’re concerned about rising costs.

Are there special cases where the pain is so great, and nothing else seems to work, where you’d agree that tapering is not appropriate? I certainly read or hear some wrenching narratives.

I believe there are some patients with severe chronic pain for whom the benefits of high dose chronic opioid therapy outweigh the risk, and those patients should continue to receive their prescriptions. But they are a small minority.

Further, even in those patients, the risk-benefit calculation could change at any moment. [Lembke co-authored a paper in the American Family Physician in 2016 entitled, “Weighing the Risks and Benefits of Chronic Opioid Therapy.”] Which is why it’s crucial to monitor risk throughout treatment, including checking the prescription drug monitoring database and talking to the patient’s family members, in addition to getting the patient’s subjective report.

In your practice, what levels of daily morphine milligram equivalents have you actually seen patients taking?  

I’ve seen people in their 80s on 800 morphine milligram equivalents daily. Walking, talking—amazing really when you consider the capacity of the body to adapt over time to opioids. To put that in perspective, the average heroin-addicted individual is on 100 morphine milligram equivalents daily. So we are seeing astronomically high doses, purely iatrogenic.

And now these people are really stuck because it’s very difficult for them to come down and off. The older people are, the less plastic their brains, making the adjustment to lower doses that much harder, but also more necessary, given the mortality risks of high dose opioids, especially in the elderly.

Are you surprised at the growing strength of the resistance to curbing opioid prescribing?

This backlash was inevitable. All along there has been a cohort of physicians who basically don’t believe in the opioid epidemic. They believe that it’s a made-up, hysterical response, that their patients haven’t gotten addicted, and that continuing to prescribe high dose opioids for chronic pain represents compassionate care. Another common refrain is that the only people who get addicted through a doctor’s prescription are addicts anyway, not victims of overprescribing. What they don’t realize is one of the biggest risk factors for addiction is simple access to a drug.

My clinical experience, and the data, show that even people with no personal or family history of addiction can get addicted to these drugs through a doctor’s prescription. Plus, you have the phenomenon of young people today who get exposed to opioids through a doctor’s prescription, like the way it makes them feel, and then they go out into the illicit market.

The stigma around heroin is different for young people today. My middle-aged and older patients are much more reluctant to use heroin. But young people don’t have that reluctance. For them it’s like: “Pfeh. Percocet from my doctor, heroin from my dealer—not that big a difference.” I have people working in high tech shooting up heroin three times a day. They might not be advertising it. But they’re not particularly ashamed of it.

You must get some angry pushback for your views.

Yeah. I regularly get hate emails and hate snail mails. When I go on radio shows I get a lot of very angry people. I try to convey to people that I’m not morally opposed to opioids. If they actually helped people long term, I would be for them. What I’m trying to educate people about is the fact that opioids can be extremely harmful when taken daily over a long period of time.

The other thing I think needs to happen, too, is a lot of support and validation for the physicians out there on the front lines. They are encountering these patients—patients who are in pain; in psychological distress. Very, very angry. Angry at the medical system. Angry at their providers. I get it. But providers are really burned out—especially the primary care doctors. We’re expecting them to take care of everything, plus manage the very difficult conversation around, “Maybe you need to go down on your high-dose opioids.” So I think supporting doctors needs to be a priority too.