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Addiction, Health Policy, Pain, Public Health

Unmet expectations: Testifying before Congress on the opioid abuse epidemic

Unmet expectations: Testifying before Congress on the opioid abuse epidemic

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My recent trip to Washington D.C. to speak before a congressional subcommittee on the problem of opioid misuse was all about unmet expectations.

First of all, I never expected to get invited to testify for the U.S. Congress. A 2012 article I wrote in the New England Journal of Medicine on the problem of doctors over-prescribing opioids to patients was picked up by Washington Post journalist Charles Lane in a piece he did, “The legal drug epidemic,” which was subsequently read by Alan Slobodin, chief investigative counsel for the House Committee on Energy and Commerce. Slobodin then sent a message to my in-box asking to “discuss the opioid abuse problem.” I almost deleted it as a hoax. But Keith Humphreys, PhD, my mentor and chief of the mental health policy section in our department, assured me it was real.

Second, not really understanding how government works beyond what I learned from the animated musical cartoon “I’m Just a Bill” when I was seven years old, and being a regular reader of the New York Times, which has almost convinced me that everyone in Washington is against everyone else and nothing ever gets done, I prepared myself for the possibility that various members of the committee might just be looking for sound bites to support their pre-ordained opinions. I was wrong.

Slobodin and his staff were curious, earnest, intelligent, and dedicated to understanding the opioid problem at the deepest level. At the hearing itself, where I and other experts testified on the problem of opioid misuse, overdose, and addiction, Congressman Tim Murphy (R-PA), and Congresswoman Diana DeGette  (D-CO) didn’t go for each other’s jugular like a couple of vampires out of Twilight, which I thought might happen. Instead, they were courteous, collegial, and again, struck me as truly dedicated to ameliorating the problem of addiction in this country.

Third and finally, I didn’t imagine that my testimony would make much of a difference, yet some of my suggestions were picked up by members of the committee, including Bridgette DeHart, a senior policy advisor for Congresswoman Yvette D. Clarke (D-NY). DeHart is a whip-smart young woman who in ten minutes of conversation conveyed to me her sophisticated understanding of the opioid epidemic. She talked about incorporating one of my suggestions – mandating physician education on the use of Prescription Drug Monitoring Databases (PDMDs) at the time of DEA-licensure – into a larger bill that Clarke and her team are working on.

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How to make alcoholics in recovery feel welcome this holiday season

How to make alcoholics in recovery feel welcome this holiday season

I was recently at a private home for a small holiday dinner with colleagues, all of whom work in the field of addiction. The host, himself a physician who treats substance use disorders, pressed a drink on a young male colleague who had politely declined the proffered glass of wine.

“Come on,” said the host, elaborating on his favorite vino, “it’s got a great bouquet.”

The young man refused again, but the host would not be deterred, and insisted that he at least try it. The room became silent, seeming to hang for a moment on the young man’s decision. He reluctantly took the drink, letting only the merest amount of alcohol pass his lips, then placed the glass on the table and did not touch it again for the rest of the evening.

I assume, though I acknowledge I may be entirely wrong in my assumption, that the young man declined the drink because he is an alcoholic in recovery – as are a sizable percentage of physicians in the field of addiction-treatment – and he was embarrassed to admit among professional peers that he abstains for this reason. Yet caught unawares, he was equally unable to conjure another explanation. If I am correct, then this scenario speaks to the need for greater general awareness among hosts about the alcoholic’s dilemma.

Addiction is a stigmatizing illness, and many individuals who suffer from addiction are careful about with whom they share this information, for good reason. ‘Recovery’ is the catch-phrase for the process whereby the addiction is treated, and for many, recovery involves abstinence from the drug of choice. The dilemma then becomes how to abstain in a context where consuming the substance is considered standard behavior, while still preserving one’s anonymity.

As we move through this holiday season and plan gatherings with friends and family – adding rum to our eggnog and whisky to our mulled wine – we might give some thought as to how to make these events as warm and welcoming as they can be for those in recovery, while still continuing time-honored traditions of serving alcoholic beverages to those who are not.

Therefore, I offer up these suggestions to guide hosts and hostesses this holiday season:

  • Serve plenty of non-alcoholic alternatives. Especially welcome are those that can ‘pass’ as alcohol, like sparkling water in a champaigne glass, or a non-alcoholic beer.
  • Host a Saturday brunch, for example, rather than Saturday dinner, when alcoholic beverages are less likely to be expected or consumed.
  • When offering alcohol to guests, offer once, and if declined, move on! Better yet, simply ask guests what they would prefer to drink, and let them generate the response, rather than forcing a ‘yes/no’ response to alcohol.
  • If you as a host are made that uncomfortable by people who do not drink, you might ask yourself what is behind that discomfort.

Naturally I look forward to the day when addiction can be openly acknowledged and accommodated, without the accompanying shame. But in the meantime, during this time between Thanksgiving and New Year’s, the heaviest drinking days of the year, be thoughtful about spreading good cheer in a way that also honors anonymity and recovery from substance use disorders.

Addiction, Pain, Patient Care, Stanford News

Why doctors prescribe opioids to patients they know are abusing them

Why doctors prescribe opioids to patients they know are abusing them

As an addiction psychiatrist, I was recently asked to consult on whether a patient hospitalized for severe low back pain suffered from opioid addiction. The odd thing about the consult was that it was obvious to even the casual observer that the patient was addicted to opioids: Her personal narrative was marked by the classic downward spiral of a drug-ravaged life, including loss of jobs, friends, family, and a recent near-death narcotic overdose; a “CURES” search, which allows authorized health care providers practicing in California to track prescriptions for controlled substances, revealed that in the past 4-5 weeks alone she had obtained prescriptions for more than 1,200 opioid pills; and two psychiatrists on two prior hospital admissions had already documented “opioid dependence”, the formal “Diagnostic and Statistical Manual of Mental Disorders” term for opioid addiction.

So why the repeat-consult to tell the primary team what they already knew? Because the patient’s treating physicians, albeit fully aware that opioids were destroying her life, were uncomfortable denying her opioids for pain and wanted validation that withholding opioids was an acceptable course of action.

As I describe in a New England Journal of Medicine Perspective piece (subscription required), physicians today experience intense professional pressure to prioritize pain treatment above other competing clinical issues. And the reasons are as much cultural and financial as related to the healing arts:

  • Patients now evaluate their doctors on customer satisfaction surveys which can influence professional advancement and national reputation, and doctors who deny patients’ requests for pain pills are likely not to get very good survey ratings.
  • Today’s cultural ethos of ‘all suffering should be avoided’ encourages patients to believe that any level of subjective pain is unacceptable, and that doctors have a responsibility to remove the pain, lest the patient, in addition to being in pain, is psychologically traumatized by having to experience pain.
  • Writing a prescription for opioids is fast, easy, and readily reimbursed by third-party payers, whereas targeting addiction requires time, is complex, and is seldom financially rewarded.

My article goes on the make some recommendations about how these problems might be addressed. But until there’s a cultural paradigm shift in which addiction is acknowledged by patients, doctors, and third-party payers as a disease that inflicts its own kind of suffering and demands its own treatment, the current national epidemic of prescription opioid abuse will continue.

Anna Lembke, MD, is an assistant professor of psychiatry and behavioral sciences at Stanford.

Addiction, Pediatrics, Public Health

To reduce use, educate teens on the risks of marijuana and prescription drugs

According to a study published this week in the Journal of Adolescent Health, non-medical use of prescription medications like Vicodin and Adderall is rising among teens. Marijuana is also on the rise among adolescents, with the National Institute on Drug Abuse reporting 22 percent of 12th graders using it in the past month. Otherwise illicit drug use among teenagers has not increased in the last decade, and teen cigarette smokers have actually decreased, with fewer teens now smoking cigarettes than marijuana.

One potential explanation for the rise in prescription medication and marijuana misuse and abuse among teens, in contrast to other substances of abuse like tobacco, is the fact that prescription drugs and marijuana are viewed in contemporary medical and lay culture as having “medicinal” properties. Both Vicodin and Adderall have FDA-approved indications, the former for pain and the latter for attention deficit disorder. Although marijuana is a Schedule I drug at the federal level, meaning it has not been approved for any medical use, marijuana is readily available for chronic pain, anorexia, intractable nausea, and other ailments in many states through dispensaries.

Teens may be using… because they have embraced the idea that these substances are good for them, or at least not necessarily bad for them

Teens may be using Vicodin, Adderall, and marijuana in increasing numbers and with increasing frequency because they have embraced the idea that these substances are good for them, or at least not necessarily bad for them. For teens who have received a diagnosis of chronic pain or attention deficit disorder, they may justify ongoing abuse as necessary to “treat” their disorder, even in the face of obvious addiction. Furthermore, withdrawal from substances of abuse is almost universally characterized by anxiety, depression, insomnia, and attention problems. Adolescents as well as adults may misconstrue symptoms of withdrawal as indicative of an underlying physical or psychiatric disorder, which in turn perpetuates use.

What is needed to combat this alarming trend in illicit drug use among teens is to launch state and national campaigns alerting adolescents to the true dangers inherent in misuse and abuse of prescription medications and marijuana, as perceptions among teens of potential harmfulness correlates with decreased use. Such a campaign would also seek to re-stigmatize use of these substances, just as national anti-smoking campaigns stigmatized cigarette smoking to the point where prevalence rates decreased by 20-30 percent in just a couple of generations, and smoking cigarettes has been banned from almost all public venues.

Cultural narratives, in other words, around specific substances of abuse, are central to influencing behavior, especially among teens who may be more susceptible than adults to the stories we tell.

Previously: How to prevent prescription-drug misuse among teens, Do people really get addicted to marijuana? and NIH podcast reveals prescription drug abuse more prevalent in teenage girls than boys

Anna Lembke, MD, is an assistant professor of psychiatry and behavioral sciences at Stanford.

In the News, Medicine and Society, Patient Care, Technology

A downside of electronic health records: How 90 percent of Merced County, California patients became Albanian

A downside of electronic health records: How 90 percent of Merced County, California patients became Albanian

Electronic medical records have become an essential backdrop to modern medical practice. Paper charts, not long ago the mainstay of health-care documentation, have become antediluvian. Whereas once doctors used to write notes with pen and paper and insert the paper into a physical binder, doctors now keep track of patients by clicking keys on a keyboard and entering data into a computer software program.

One of the great advantages of the electronic medical record over its ancestral precursor ‘notes-in-a-binder’ is that records are now centralized and can be accessed by multiple authorized care providers, such that it is possible to know what treatment a patient received from any health-care provider working in the conjoined medical system, from primary care visits to hospital admissions. Physicians are less siloed within specialties and more able to share information.

This week’s Science section of the New York Times discusses the upsides and the downsides of modern technology in the medical workplace, but one of the downsides that isn’t emphasized is the fact that much of the data entered into electronic medical records is being mined to make important decisions about clinical care and health policy. And if data-mining is based on inaccurate information, then the whole operation is a house of cards. Let me cite one example.

A physician I know in Merced County, California has been practicing medicine for the greater part of three decades, and he was recently obliged by his medical group to transition from paper to electronic medical records. The medical-records software he uses mandates that he indicate on a pull-down menu the ethnicity of each of his patients. He views his patients’ ethnicity as non-essential to his practice, and so – pressed for time like most health-care providers – he clicks on “Albanian” for all of his patients, not because they are Albanian, but because “Albanian” is the very first item on the pull-down menu and therefore the fastest to access. The result is that over 90 percent of his patients appear to be Albanian, when in fact they represent the usual constituents of Merced County, with few if any Albanians among them.

Misinformation in electronic medical records, whether accidental or otherwise, has far-reaching consequences for patients and health care policy, because electronic medical records are being actively ‘data-mined’ by large health care conglomerates and the government as a basis for improving care. This is an important downside to consider as we move forward.

Previously: Health-care experts discuss opportunities and challenges of mining ‘big data’ in health care, Mining for research: How computerized records open new doors for medical researchers and More health-care providers embrace the high-tech office

Anna Lembke, MD, is an assistant professor of psychiatry and behavioral sciences at Stanford.

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