I went to medical school knowing I wanted to pursue primary care and have been doing so for 28 years. Being a doctor is so much more than prescribing medicine, it is getting to really know you, taking time to listen and understand your life situation, your aspirations and even fears. There are many determinants of someone’s health: your past experiences, your current circumstance, and your goals for the future all need to be taken into account. I consider it a privilege to know my patients over many years and to be able to help you achieve fulfillment in life despite ailments, acute or chronic.
If you would like to know my past, present, and future goals, I’ll tell you briefly that I was born and raised in Belgium, came to the US at age 19 to study at UCLA and UCSF Medicine, and met an earthquake researcher who has been my husband for 33 years. We have two children, both in college. I love to travel, hike, garden, take photographs but above all, spend time with my family. I hope to keep practicing medicine for many more years and thus continue to meet people from all around the country and world who teach me so many valuable life lessons. I feel fortunate to be part of the Stanford community.
- Internal Medicine
Clinical Assistant Professor, Medicine - Primary Care and Population Health
Clinical Lead, Santa Clara County Opioid Overdose Prevention Project (2015 - Present)
Leading member Opioid Safety Task Force, STANFORD SCHOOL OF MEDICINE (2018 - Present)
Director Tully Primary Care clinic, Santa Clara County Health and Hospital System (2012 - 2014)
Director Tully clinic express Care Clinic, Santa Clara County Health and Hospital System (2011 - 2014)
Honors & Awards
Award for Advocacy and Community involvement, Society Of General Internal Medicine, California and Hawaii region (4/2019)
Leadership Award, Santa Clara County Behavioral Health Departement (10/2019)
Teacher of the year, Santa Clara Valley Health and Hospital System Residency Program (1994)
Boards, Advisory Committees, Professional Organizations
Fellow, American College of Physicians (2019 - Present)
Medical Education: University of California at San Francisco School of Medicine (1991) CA
Chief Residency, Santa Clara Valley Medical Center (1995)
Residency: Santa Clara Valley Medical center (1995)
Board Certification: American Board of Internal Medicine, Internal Medicine (1994)
Community and International Work
Regional Opioid Safety Coalition for Santa Clara County
California Health Care Foundation and Santa Clara County Department of Alcohol and Drug Services
Opportunities for Student Involvement
Current Research and Scholarly Interests
The EMPOWER study- a patient centered opioid tapering study for patient with chronic pain on long-term opioid therapy. Funding: PCORI PI: Dr Beth Darnall
Studies suggest that long-term opioid use for chronic pain does not help reduce pain or help patients live fuller lives. Opioid medications have major health risks, even when taken exactly as prescribed, including worsening pain. There are no studies that tell prescribers how to best address their patients’ concerns and engage them in opioid reduction, and how to best help them achieve meaningful and successful outcomes that last long-term.
Our patients told us that for opioid reduction to be successful, the benefit of lower dosage needs to be well understood by them. Further, the patients want to work with their doctors to create together such opioid reduction treatment plan. Based on such input, we developed a patient-centered study that encourages patient interest and willingness to actively and collaboratively reduce opioids use and test 2 well established behavioral intervention pain treatment.
Study aims: We will test which of the two types of pain management classes described below is best for reducing pain and pain interference, increasing function, and reducing opioids within the context of active, collaborative, patient-centered opioid reduction that addresses their main concerns.
Study description: We will study the effectiveness of two types of active behavioral pain management treatment classes in patients prescribed long-term opioids from primary care and pain clinics in 4 states in the Western U.S. Patients who wish to reduce opioids will collaborate with their doctor to co-create a tailored plan to reduce their opioids. Recognizing that some patients are not ready to reduce opioids, we will also enroll patients who decided not to increase their opioid dose during the one-year study period (opioid dose containment group). All study patients will be assigned to either 8-week group Cognitive Behavioral Therapy for chronic pain, 6-week peer-led Chronic Pain Self-Management Program, or no behavioral treatment. Our two active behavioral treatment groups are evidence-based and widely available. We will determine which behavioral treatment works best and for whom for pain control, functioning and opioid reduction at 12 months within the context of collaborative opioid reduction. We will determine whether the behavioral treatments help improve readiness to reduce opioids for those who elected to hold their opioid dose constant. Our primary outcomes were informed by our patient stakeholders and include pain intensity, opioid use, pain interference, role function, anxiety, depression, pain catastrophizing, sleep, fatigue, and medication side effects. Patients with any type of chronic pain may enroll except for such patients with active addiction, behavioral or safety concerns. Our project focuses on community outpatient settings where most U.S. patients receive prescribed opioids. Our project is designed such that the results can be broadly applied to anywhere in the US.
Cognitive Behavioral Therapy and Chronic Pain Self-Management Within the Context of Opioid Reduction: The EMPOWER Study
The proposed study will fill several critical gaps in evidence that are preventing patients and physicians from making informed decisions about their pain care. This project will provide patients taking opioids and physicians with the specific evidence they need to choose the most effective route to pain control, reduced pain interference, opioid reduction, and improved role function, thereby improving patient care. The aims of this study are to (1) reduce or contain prescription opioid use while maintaining pain control and (2) compare the effectiveness of the Chronic Pain Self-Management Program (CPSMP), Cognitive Behavioral Therapy for chronic pain (pain-CBT), and no behavioral treatment within the context of patient-centered collaborative opioid tapering (Taper Only). The acronym EMPOWER stands for Effective Management of Pain and Opioid-Free Ways to Enhance Relief. To learn more about the EMPOWER study, please visit: empower.stanford.edu.
A Patient Education Video on Opioid Tapering, Stanford University- Department of Medicine
Department of Medicine funded project to educate patients on how opioid tapering is done.
Through the story told by a real patient who tapered off opioid medications over a two year period, and using animated images we walk the viewers through the process of tapering, discussing the rationale for tapering, how it is done, what to expect in terms of both potential withdrawal symptoms and long term benefits, and a brief discussion on self-care with chronic pain syndromes. Based off the Stanford CME course by Dr Anna Lembke on Opioid Tapering. https://www.youtube.com/watch?v=BCtYqEOjK-Y&feature=youtu.be
- Jessica Whittemore, Instructional Designer Dvlpr 1, Technology & Digital Solutions, Technology & Digital Solutions
For More Information:
A Brief Screening Tool for Opioid Use Disorder: EMPOWER Study Expert Consensus Protocol.
Frontiers in medicine
2021; 8: 591201
Growing concerns about the safety of long-term opioid therapy and its uncertain efficacy for non-cancer pain have led to relatively rapid opioid deprescribing in chronic pain patients who have been taking opioid for years. To date, empirically supported processes for safe and effective opioid tapering are lacking. Opioid tapering programs have shown high rates of dropouts and increases in patient distress and suicidal ideation. Therefore, safe strategies for opioid deprescribing that are more likely to succeed are urgently needed. In response to this demand, the EMPOWER study has been launched to examine the effectiveness of behavioral medicine strategies within the context of patient-centered opioid tapering in outpatient settings (https://empower.stanford.edu/). The EMPOWER protocol requires an efficient process for ensuring that collaborative opioid tapering would be offered to the most appropriate patients while identifying patients who should be offered alternate treatment pathways. As a first step, clinicians need a screening tool to identify patients with Opioid Use Disorder (OUD) and to assess for OUD severity. Because such a tool is not available, the study team composed of eight chronic pain and/or addiction experts has extended a validated screening instrument to develop a brief and novel consensus screening tool to identify OUD and assess for OUD severity for treatment stratification. Our screening tool has the potential to assist busy outpatient clinicians to assess OUD among patients receiving long-term opioid therapy for chronic pain.
View details for DOI 10.3389/fmed.2021.591201
View details for PubMedID 33869240
Comparative Effectiveness of Cognitive Behavioral Therapy for Chronic Pain and Chronic Pain Self-Management within the Context of Voluntary Patient-Centered Prescription Opioid Tapering: The EMPOWER Study Protocol.
Pain medicine (Malden, Mass.)
Evidence to date, while sparse, suggests that patients taking long-term opioids require special considerations and protections to prevent potential iatrogenic harms from opioid de-prescribing, such as increased pain or suffering. Following this study protocol, the EMPOWER study seeks to address multiple unmet needs of patients with chronic pain who desire to reduce long-term opioid therapy, and provide the clinical evidence on effective methodology.EMPOWER applies patient-centered methods for voluntary prescription opioid reduction conducted within a comprehensive, multi-state, 3-arm randomized controlled comparative effectiveness study of three study arms (1) group cognitive behavioral therapy for chronic pain; (2) group chronic pain self-management; and (3) usual care (taper only). Specialized electronic data capture systems collect patient reported symptoms and satisfaction data weekly and monthly during the taper, with real-time clinical alerts and electronic feedback loops informing, documenting, and steering needed care actions.The EMPOWER study seeks to provide granular evidence on patient response to voluntary opioid tapering, and will provide evidence to inform clinical systems changes, clinical care, patient satisfaction, and patient outcomes for opioid reduction.
View details for DOI 10.1093/pm/pnz285
View details for PubMedID 31876947
Massive leptomeningeal amyloidosis associated with a Val30Met transthyretin gene
1996; 47 (4): 988-992
We report a 69-year-old woman of Mexican origin with a 6-year history of progressive paresis, mild peripheral neuropathy, and recent onset of fluctuating mental status. Head and spinal MRI revealed contrast enhancing thickened meninges which on biopsy disclosed amyloid deposition. Immunohistochemistry identified the amyloid as transthyretin (TTR), and polymerase chain reaction/restriction fragment length polymorphism analysis of blood revealed a Val30Met mutation in one of her TTR genes. This mutation causes familial (hereditary) amyloidotic polyneuropathy of the Portuguese type (FAP 1). However, unlike FAP 1, in which peripheral neuropathy is a dominant feature, our patient's clinical manifestations, which included communicating hydrocephalus and myelopathy, were more suggestive of familial oculoleptomeningeal amyloidosis (FOLMA). In summary, the clinical presentation of TTR Met 30 mutation is more varied than previously suspected, and leptomeningeal amyloidosis should be considered in the differential diagnosis of obscure conditions involving meninges.
View details for Web of Science ID A1996VN29500024
View details for PubMedID 8857732
- PULMONARY TUBERCULOSIS, AMENORRHEA, AND A PELVIC MASS WESTERN JOURNAL OF MEDICINE 1994; 161 (5): 515-518
ANGIOTENSIN II-INDUCED RHYTHMIC JAW MOVEMENTS IN THE KETAMINE-ANESTHETIZED GUINEA-PIG
1989; 478 (2): 233-240
The EMG activity of the left anterior digastric muscle as well as associated jaw movements were studied in ketamine-anesthetized guinea pigs that had received i.v. infusions of angiotensin II (ANG-II). Rhythmic jaw movements with two distinct movement profiles were associated with ANG-II infusion. One movement profile was typified by vertical jaw opening and closing movements with little or no associated horizontal movement. The second rhythmical jaw movement profile was unlike the first in that jaw closing was accompanied by a significant horizontal deflection of the jaw. Both jaw movement profiles were similar in that little or no horizontal movement occurred during jaw opening. Tongue protrusions were also observed during jaw opening in both cases. The results show that ANG-II induces rhythmic jaw movements in anesthetized guinea pigs. ANG-II-induced jaw movement profiles and digastric muscle EMG activity are similar to those seen after an i.v. injection of apomorphine in the anesthetized guinea pig, and to those associated with lapping in the awake animal.
View details for Web of Science ID A1989R855700004
View details for PubMedID 2924127