The Director of Stanford’s Addiction Medicine Program, caught between protocol and her own bruised ego.

Dr. Anna Lembke caused quite a stir in 2012 when her perspective piece Why Doctors Prescribe Opioids to Known Opioid Users was published in the New England Journal of Medicine. In it, she delivered a no-holds-barred accounting of the reasons why patients with histories of addiction receive opioid pain medication from physicians. Here she helps us see behind closed doors in the clinical practice of addiction medicine, as she grapples with a variety of forces that factor in to her decision-making in providing care to a well-known patient.

As I scanned the schedule of patients I would be seeing that day, my eyes hovered on my 10 am visit – Sophie. I felt a warm glow as I anticipated meeting with her. I’d been seeing her for more than 2 years, and I liked to think that my initial involvement in her care propelled her into recovery. She’d been addicted to prescription stimulants, opioids, and benzodiazepines when she first came through my clinic, telling herself and anyone else who would listen that her use was legitimized by her ADHD, lower back pain, and anxiety.

Through a combination of my work with her – I guess some would call it motivational interviewing, but when I trained it was just called psychotherapy – and a cohort of doctors who were no longer willing to prescribe the meds she craved, she went into a 30-day rehab. When she got out, she relapsed, but after another rehab and lots of Narcotics Anonymous (NA), she managed to put together a solid program.

Over the next couple of years she checked in with me monthly. Life wasn’t perfect, but so much was better: She was getting along with her mom, she’d started working again, she was dating. She was very involved in NA, had a sponsor, and at one point even started her own group. She would proudly tell me whenever a new sobriety milestone arrived, the days accumulating into weeks, months, and even years, and she’d show me each NA chip that she earned.

On this particular day, I prepared for her visit by doing what I always do –  I checked our state’s prescription drug monitoring program, “CURES,” which allows me track any and all controlled medications (Schedules II, III, and IV) a patient has picked up from a pharmacy in the prior 12 month period. I was expecting to see the minimal benzodiazepines I prescribed her for sleep, something I had continued after her second relapse as part of a harm reduction strategy. Instead what came up, to my surprise, was a prescription for Tramadol.

Tramadol is a centrally acting opioid analgesic first approved for use in the U.S. in 1995 under the name “Ultram.” It was initially advertised as merely “opioid-like,” because Tramadol is an atypical opioid which acts primarily as a serotonin-norepinephrine reuptake inhibitor, and is actually a fairly weak μ-opioid receptor agonist. I vividly remember my medical colleagues who prescribed Tramadol specifically advocating its use to avoid addiction.

However, and this is a big “however,” Tramadol is metabolized in the body to O-desmethyltramadol, which is a more potent opioid receptor than the parent compound. In other words, it starts off as a weak opioid agonist, and turns into a stronger one after ingested. In recent years, data has shown that Tramadol is an addictive drug. The Drug Abuse Warning Network (DAWN), a federally-operated, national surveillance system that monitors trends in drug-related emergency department visits, reported a 165% increase, including more than 12,000 cases, in drug-related emergency department visits mentioning Tramadol from 1995 to 2002. A few months ago, the DEArescheduled Tramadol as a Schedule IV drug – it had previously been unscheduled – thereby communicating its abuse potential and making it possible, among other things, to be monitored using prescription drug monitoring programs, like the one I use.

When Sophie arrived for her visit, I felt nervous, wondering how I would broach the subject. She started in telling me how well she was doing, about the meetings she was attending, the step she was working on, her job prospects, etc., etc.

“Um,” I said, not the most propitious of beginnings, “I…uh…noticed on the CURES report that you recently got a prescription for Tramadol.”

She acted nonchalant. “Oh that? Yeah. It’s for my back…you know, my pain.”

“Have you been taking it long?”

“About 2 years.” My heart dropped somewhere close to my lower spleen. Two years?! And all this time I thought she was opioid-free? I tried not to show my amazement and disappointment. I was experiencing the unwelcome retribution of being narcissistically-invested in my patient’s outcome.

“Why didn’t you tell me? It’s an opioid.”

“Well, I didn’t know that. My back doctor told me it wasn’t addictive, so I didn’t think it was a big deal.”

“You do realize it’s an opioid, right? I mean it doesn’t start out as a strong opioid, but it’s metabolized into a powerful opioid with risks for tolerance, dependence, and addiction.”

She looked at me, her eyes narrowing. “It helps my low back pain. I don’t misuse it.”

This was not going well. “I’m also worried because you’re taking the benzodiazepine too. An opioid and benzodiazepine in combination increase your risk of trauma and accidental overdose. You could die.”

“Look. I’ve been taking it for a long time without a problem, and when you didn’t know about it, you weren’t worried about it and thought I was doing well. I am doing well, and I’m not going to stop taking it, so just give it up. Anyway, you’re my doctor, not my probation officer.”

And the winner is…Sophie.

I really didn’t have much of an argument beyond what I had already made, and she had the stronger point. As long as I hadn’t known she was taking Tramadol, I’d thought she was doing fine. Now that I knew, due to a change in regulatory accounting, did that somehow negate the objective evidence of her improved function over the past two years? If another doctor was giving her Tramadol for pain, and she wasn’t abusing it, how was that any different than my giving her a small dose of benzodiazepines for sleep? But I was still worried.

I was worried about the cumulative effects of the opioid and the benzos, a combination which has been shown to increase the risk of accidental overdose above that caused by either medication alone. I was worried about polypharmacy, which broadly increases the risk of delirium and is never a good idea for patients with addiction, for whom “chemical coping” should be a discouraged method of adaptation. I was also worried that she hadn’t told me about it, since lying is often a harbinger of compromised recovery. I ask about all medications, and she’d consistently left that one out.

My difficulty with Sophie touches on the larger issue of how to readjust discussions with patients and treatment plans once a medication that was previously thought to be non-addictive, is discovered to be addictive. The classic example is heroin, which was marketed for years by Bayer Pharmaceutical as a non-addictive alternative to morphine, and sold over-the-counter alongside aspirin. Who knows if other medications I currently recommend as “non-addictive alternatives” will prove themselves addictive in the years to come? I shuddered when I recently read a case report of a patient who became physiologically dependent on and addicted to gabapentin. Not gabapentin?!

Sophie and I agreed to hold the course with her medications, although I felt uneasy, and she felt resentful. Read more “the fix”…