In the 1980s, a well-intended shift in the use of opioids for pain management began taking hold in medical communities. Past fears of addiction gave way to the desire to do more for patients in pain, particularly hospice patients.
“The problem was, by the end of the 1990s, we were dispensing opioids like vending machines,” Dr. Anna Lembke said to medical professionals at Montrose Memorial Hospital’s Fall Clinic Sept. 28.
“Pretty much anybody who walked into the office and said ‘I have pain’ (would be prescribed) and today, we’re facing the worst opioid epidemic in U.S. history.”
Lembke, the chief of the addiction medicine dual diagnosis clinic at Stanford University School of Medicine, is also the author of “Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop.”
It is now well-known that opioids are powerfully addictive, but, even now, doctors are over-prescribing opioids as painkillers.
As opioid-prescribing has quadrupled, so have opioid overdose deaths, Lembke said — and so-called “pill mill” doctors who do it on purpose for profit are not the main cause.
“It’s essential to realize it is not driven by a small subset of prolific prescribers. We are all prescribing too many opioids,” Lembke said.
In Colorado, 60 opioid prescriptions per 100 persons were written in 2016, Lembke said, citing Centers for Disease Prevention and Control data. In Montrose County, the rate was 80 prescriptions per 100 people.
“We are now in the second wave of this epidemic,” she said.
Additionally, opioid prescription misuse, addiction and related deaths have transferred to illicit opioids like heroin and the much more potent fentanyl.
Although deaths from prescription opioids have been going down, they remain at very high levels and, to-date, still outstrip deaths from illicit opioids.
“We still have very serious prescription opioid problems,” Lembke said.
Lembke in her address touched on another “hidden, over-prescribing problem” — benzodiazepines. When used in conjunction with opioids, these increase the risk of death nearly fourfold, and remain potentially fatal on their own.
In physician-specific information, Lembke spoke of the “medicalization of poverty,” as well as other pressures doctors face, as more and more become the employees of large, integrated health centers, which base things like pay and promotion on patient satisfaction.
A patient addicted to opioids is unlikely to be happy if confronted or denied a prescription, a point Lembke later drove home in video reenactments.
Additionally, in the last three years, physicians are being increasingly asked to also address patients’ psychological and socio-economic problems, “but we have not been given the resources to do this,” Lembke said, calling this the medicalization of poverty and an invisible force inside the medical system.
“We are forced to bio-medicalize problems that are not in fact biological, or if we do that, we prescribe a pill.”
Lembke also probed cultural narratives that have caused people to believe pain is dangerous and the body cannot heal itself. The same type of narrative casts the doctor as “superman,” she said.
She also tackled myths surrounding opioids.
There is no evidence opioids are effective for chronic pain beyond 12 weeks and the evidence that exists for the efficacy of shorter periods is flimsy — as well as funded by drug makers, Lembke said.
Another myth: That fewer than 1 percent of people who were prescribed opioids by a doctor for a bona fide pain condition will become addicted.
“That is not true,” Lembke said.
Instead, the evidence shows 25 percent of such patients will develop opioid misuse (taking the drug for other than its prescribed purpose), and of these, 10 to 15 percent become addicted.
“The fact that we haven’t been able to make more progress, the fact that, despite our increased awareness about there being an epidemic and major problem … I think it warrants a deeper look,” Lembke said earlier in her address.
“I would argue that this epidemic is really the canary in the coal mine because it is in fact the symptom of a faltering health care system that opioids have become the solution, not to a patient’s problems, but to doctors’ problems.”
Katharhynn Heidelberg is an award-winning journalist and the senior writer for the Montrose Daily Press. Follow her on Twitter @kathMDP.