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About Anna Lembke, MD
Dr. Anna Lembke received her undergraduate degree in Humanities from Yale University and her medical degree from Stanford University. She is on the faculty of the Stanford University School of Medicine, a diplomate of the American Board of Psychiatry and Neurology, and a diplomate of the American Board of Addiction Medicine. She is the Program Director for the Stanford University Addiction Medicine Fellowship, and Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. She has published over 50 peer-reviewed articles, chapters, and commentaries, including in the New England Journal of Medicine, the Journal of the American Medical Association, the Journal of General Internal Medicine, and Addiction. Dr. Lembke sees patients, teaches, and does research. She is the author of a book on the prescription drug 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).
Dr. Anna Lembke’s key areas of interest include treating patients who have become addicted to prescription drugs. She takes a holistic, harm-reduction approach to each patient, and encourages spiritual and alternative therapies in the process of healing.
Dr. Lembke’s Intake Department: 650-498-9111
02:14 History of the Opioid Epidemic: In the 1980 there was a movement within medicine to try to improve the treatment of people with pain. It was at the same time as the rise of the hospice movement, which focused upon making the transition from life to death more peaceful. Big pharma’s involvement lead to increased opioid prescribing. Even regulatory boards became more supportive of more opioid use. There were two major opioid epidemics in the US prior to 1980. One was in the early 1900s when heroin was prescribed and available over the counter. In the 1960s there was another heroin epidemic. Prior to the 1980s, opioids were only used end of life or for comprehensive trauma. In the 1980s we thought that opioids were effective for chronic pain long term, but that is not correct. They are only effective for 3 to 7 days. They can increase pain by changing your pain threshold. Doctors were told that the chance of addiction for pain use was very low. That is also not true. Rates of addiction for those of us using prescribed opioids is between 10 and 50%. The longer you take it and the higher the dose, the higher your risk of addiction. Doctors were told that no dose is too high.
07:36 Opioid Epidemic: In 2011 the CDC declared an opioid epidemic caused by over prescribing of opioids by doctors.
08:36 Incentive for Over Prescribing: Individual doctors are not receiving kickbacks from the pharmaceutical companies. Our healthcare delivery system is in turmoil. Some primary care docs see upwards of 40 patients a day and see them for less than 15 minutes. Prescribing pain meds is a tool.
09:52 Change in Medicine: Dr. Lembke calls it the Toyotatazation of medicine. The focus on body parts has replaced full body health as the focus of medicine. It is an assembly line approach. Prescribing pain meds satisfies patients.
10:46 Infiltration of the Pharmaceutical Industry: The lobbyists in Washington are doing their jobs and the watchdog organizations, like the FDA, are not doing their jobs.
11:58 Tolerance: Tolerance is needing more of the medication to get the same effect. It inevitably happens in people who take opioids long term. Neuroadaptation occurs in the brain. Your brain continually adjusts to create equilibrium, including increasing your sensitivity to pain. When the drug is taken away, or between doses, people experience withdrawal. One symptom is full body pain.
13:30 Other Side Effects: Long term opioid use can cause constipation, depression, serious cognitive problems like memory issues, sedation, hormone imbalances, suppressing testosterone and estrogen, increase cardiac risk, risk of heart attack, and the risk of accidental overdose and death.
14:06 Effects of Opioids: Opioids slow your drive to breathe and your heart rate. Even if your develop tolerance to the pain relieving aspects, you do not develop tolerance to the respiratory effects. In 2014, there were over 16,000 deaths from opioid pain medications. A large percentage of this group were using the medication as directed.
15:19 Safe Alternatives: The CDC opioid prescribing guidelines say that doctors should dispense no more than 3 days of opioids. Ideally, we would use non-opioid pain relievers like aspirin, Tylenol, or ibuprofen. In conjunction, you could use ice or cold pack, rest, trigger point injections, trigger therapy, acupuncture, psychotherapy, and/or mindfulness meditation.
16:23 Perioperative Opioid Use and Healing: A recent study showed that people who received opioids perioperatively had slower healing than those who did not. Opioids retard the healing process.
18:03 Predisposition to Addiction: There may be a large genetic component to the risk of becoming addicted. If you have a parent or grandparent with a history of addiction, you are about a 4 fold increased risk of developing a substance abuse problem. Biology is not destiny. Others have no family history, yet develop an addictive disorder.
19:35 Risk Factors for Addiction: Access is a risk factor, as is co-occurring psychiatric illness. Risk increases with the experience of trauma or growing up in a family that condones substance abuse as an adaptive coping strategy. It is a biopsychosocial illness, because there is a biological component, and there are psychological factors and social environmental factors. People who believe in a higher power or actively participate in religious activities have lower rates of addiction.
22:19 Lessons from the Highly Addicted: In China, Dr. Lembke went to a hospital that was dedicated to people who were addicted to heroin. Heroin use is stigmatized and they incarcerate addicts to prison camps. Dr. Lembke spoke to heroin addicts who spent their own money to receive treatment. Methadone and a little psychotherapy was used to get them off heroin. One patient told her that he had the addiction surgery. It appears to be a naltrexone implant into his abdomen. Naltrexone is a drug that blocks the opioid receptor, preventing opioids from binding. Because he was not educated about what the implant was supposed to do, he man kept shooting up heroin until the naltrexone wore off. Medication alone will not solve the complicated behaviors around addiction.
26:32 Environment’s Impact upon Addiction: Addiction is a learned behavior. Our external cues trigger those behaviors. You need to avoid the people, places and things that you used with. Reintroduction to those former people, places or things can trigger cravings. If you want to change your behavior, you need to come up with a new reward for the new behavior.
29:11 Addiction Treatments: There are self-binding techniques. Install barriers to our drug of choice. Anticipate vulnerable moments in advance and plan an alternate behavior.
31:26 Family Resources: Addiction functions like a family disease, because everyone is affected. Family members may enable the substance use. Families benefit from education and counseling. The most effective addiction treatment involves families. Sometimes the best thing you can do is remove yourself, as a family member.
32:50 Frontal Lobe Involvement: Many talk about addiction being a disease of your ability to choose, thus being a frontal lobe cognitive function disease. In the throes of addiction, people are cognitively impaired. People can benefit from a treatment setting where they have no access to drugs and alcohol for at least 4 weeks, or, for adolescents, a therapeutic boarding school. The break allows the brain to rebalance to a level brain function in a healthy range.
35:59 Use vs Addictive Use: There is a hypocrisy in our society about legal drugs and illegal drugs. Illegal drugs, in some cases, are no more dangerous than legal substances. In Portugal, all drugs are legal and there is no spike in addiction. It is the way people use drugs, the frequency, the quantity and their attachment to them.
36:58 Dopamine: The dopamine hit in addictive drugs is very high and causes a stress response in our bodies. It is a huge stressor on our bodies. Our brains are adapted to have to put in a lot of effort and only get a very small dopamine hit.
39:04 How Much is Too Much? An adult male should have no more than 2 standard drinks per day or 14 per week. An adult female should have no more than 1 standard drink per day or 7 per week. This should keep the hedonic set point from shifting. Higher consumption is linked to cancer, liver issues, motor vehicle accidents, and death. There is no data on safe amounts of recreational marijuana use because it is still a schedule 1 drug on the federal level. Even one cigarette a day increases risk of cancer. Don’t use substances to change the way you feel on a daily basis.
42:32 Dr. Lembke’s Elevator Speech: Educate people more broadly about addiction. The current system incentivizes doctors to over prescribe. Until we address the incentives and educate doctors to recognize addiction, we will not be able to get out of this opioid epidemic. The doctor/patient relationship is one of the most important healing factors.