Insanity of Politicized Medicine

In 1668, Joseph Glanville wrote Against Modern Sadducism, in which he argued that not only do witches exist, but that he could detect them, railing against the denial of supernatural spirits (as opposed to the bottled kind, I guess) and lamenting the public’s tolerance of witchery.  Though not a scientist himself, he became “the most skillful apologist virtuoso” of what was called natural philosophy.  Natural philosophy was an early name for what we now call science. Although it was headed in the right direction, opinions and appeals to authority trumped evidence back then, just as they sometimes still do today.

Glanvill was a Puritan educated at Oxford and respected the Platonists of Cambridge, following a long historical tradition of taking the words of a past luminary and treating them like holy writ.   He was a complicated man, first writing, The Vanity of Dogmatizing, to attack scholasticism and religious persecution with a plea for religious tolerance and the scientific method.  Then went on to write his screed against the denial of the existence of witchcraft, citing religious authorities, and described a “witch bottle” for protection from the dastardly minions of Satan.  Dichotomous concepts like these are common in human psychology. Despite his contradictions, Glanvill’s works highlight the importance of understanding historical perspectives in shaping all about health efforts and healthcare ideologies.

Glanvill died in 1680, long before Cotton Mather was inspired by his writings to create the Wonders of the Invisible World, a defense of the Salem Witch Trials.  In both the case of Glanvill and Mather, we see men who start in science and end in conjectural destruction of everything that science stands for.  True science is about one thing: the search for truth; it is not about political popularity, monetary rewards, or enforcing opinion by law.  If it’s objectively true, it is science; all else is conjecture. Mather’s contribution to the discussion of witch-hunting after the deaths of many innocents was to argue that it ended too soon.

Not to be outdone by their forbears, the Massachusetts House introduced Bill 3656 on January 22, 2019, “An Act requiring practitioners to be held responsible for patient opioid addiction.” Section 50 of this proposed legislation reads, “A practitioner, who issues a prescription for a controlled substance placed in Schedule II, which contains an opiate, shall be liable to the patient for whom the written prescription was written, for the payment of the first 90 days of in-patient hospitalization costs if the patient becomes addicted and is subsequently hospitalized.” How the heck did this happen?

Can you imagine an orthopedic surgeon being told, “If you use an antibiotic and the patient gets a drug-resistant infection, you must pay the first 90 days of their hospital, ICU, and surgical care because your use of the initial antibiotic put them “at risk” of a resistant infection?”  The reasoning, or lack thereof, is equally sound. How did we get here?  How did we get from evidence-based medical care to a demonization of an entire class of medications?  With the help of sometimes well-paid and perhaps even sometimes well-meaning medical professionals who believe that their outlier and even extreme opinions should be enforced by law.

It turns out that the legislator who introduced the bill had fallen under the thrall of an addiction psychiatrist who had no training or clinical experience treating chronic pain.  This brings me to an important point.  The treatment of pain in America is now being almost completely dictated by anesthesiologists who have gone on to become interventional pain specialists.  This is different from medical pain management specialists, who often come from PM&R, Emergency Medicine, Internal Medicine, General Medicine, and Psychiatry.  The interventionists believe in their skills and don’t think you need medications so much as just one more steroid injection into your spine.

Sure, the injections might have failed in half the people who get them, including you, but if you refuse to get another one and just ask for continued medical treatment, you are “drug seeking.” These are the specialists most often found on pain committees and state advisory boards. Telling everyone how “bad doctors” just prescribe pills, while “good doctors” do procedures.  This is a false dichotomy.  Medical pain management is when a primary care physician offers pain treatment to those who have been through all the shots and injections that can reasonably be asked of them and still have severe, intolerable pain.  This is called palliative care.

This type of practice was the standard of care for decades but is now propagated to juries as somehow illegitimate, with the DEA arguing to medically naïve juries that the physical exam was “inadequate” or that the MRI does not justify the amount of pain reported. But if the federal government is forbidden by law from trying to influence the practice of medicine (42USC1395), how does the federal government get away with making these claims?  Easy.  Just pay an outlier physician with extreme opinions to tell the jury that his personal beliefs are THE standard by which all “good” pain-treating physicians should be judged. See US v. Dr. William Bauer.

And now, these extreme positions are taking over addiction medicine, where almost any use of opiate medication is equated with the scourge of addiction,  reflecting evolving perspectives within healthcare policy and healthcare system management.  Now understand that I came to the study of addiction reluctantly. I had started my medical career studying emergency medicine and loved the ER. The ER can be a good place to learn about addiction and chronic pain if you are open to learning from others, but I quickly realized that my primary medical education was lacking in these areas.  To correct this, I sought out extra training, first with a board-certified PM&R pain specialist and then with a board-certified addiction psychiatrist, so I could see both perspectives.

Seeking extra training from specialists in pain management and addiction psychiatry exemplifies the importance of innovations in healthcare to address complex medical issues effectively. 

I worked for over a decade with the pain specialist, helping her with general medical issues, while observing and learning from her pain management expertise.  She did a few procedures, just like I will do trigger point and joint injections, as these are a skill learned in emergency medicine.  I have also performed hundreds of lumbar punctures, but I don’t do spinal steroid injections.  Just like I can perform open heart surgery in a trauma but won’t try to give you an elective bypass, I leave that to those who do it on a daily basis. So, over time, I became comfortable understanding and treating severe chronic pain.  Supplementing my experience with extra CME on the subject.

Then, I was asked to help open the first Suboxone clinic in our area.  At that time, I had taken some CME on this subject, but not enough to make me comfortable with my knowledge base, so I traveled to be trained by Harvard physicians on the latest advancements in this field.  I continued my studies, joining both the American Academy of Pain Medicine and the American Society of Addiction Medicine so that I could stay abreast of new knowledge, and I worked under the supervision of that addiction psychiatrist at the Suboxone clinic.  Then, the local methadone clinic tried to get us shut down, teaching me about the ways of big medical business.  This surprised me.

While I like being comfortable and love taking good care of my family, money has never motivated me.  I did not become a doctor to get rich.  If I wanted to get rich, I would have gotten an MBA and become a CEO.  It takes a lot less time and pays much better.  The ER doctor who fights to sew up bullet holes in a beating heart, or the neurosurgeon who saves your child after a fall and brain bleed, does not make a million dollars a year.  Much less the $32.8 million salary paid out to the CEO of Boeing in 2023. He also got a bonus of $2.8 million.  The bonus alone is more than even the neurosurgeon, despite seven years of training after medical school, can hope to make in a year.

What drives me is a deep desire to be relevant in the world and to help people.  As cliché as it sounds, when I was a child, I saw my mother, a brilliant nurse, treat the doctors where she worked with a level of respect that made an impression on me.  These men, and they were almost all men back then, walked through the hallways in their long white coats and saved lives.  What could be more noble than that?  I was hooked, and while I joined the military to further my education, there was never any doubt about what I wanted to be, though several times I doubted it would ever be possible.  Once in practice, though, I loved medicine for decades.

Then, the two most powerful forces in the world, money, and politics, took over medicine, and everything changed ,reflecting the influence of healthcare policy and healthcare system management. Starting with the healthcare privatization craze. County non-profit hospitals were bought and maximized for profit, weeding out the patients who couldn’t pay and giving outstanding care to those who could. ER contracting companies sprouted up, and doctors who had helped build the hospital itself ended up working for days on end, choosing between abandoning patients, and working when we might be too exhausted. For all the publicity on big pharma related to opiates, no one talks about the power of money in other areas of medicine.

And that brings me to a conference I recently attended.  Big pharma money has found the field of addiction medicine, and it is fertile ground. At this conference, both sides of the opiate debate were not heard, at least in the one-day-long update session I attended.  Instead, learned and credentialed medical specialists in addiction psychiatry and behavioral science waxed poetic about how pretty much all opiate pain treatment leads to addiction.  About how the only safe pain treatment is buprenorphine, and if someone is not satisfied with their pain levels after treatment, they are drug seeking. That you can’t trust most patients and never, ever traumatized women.

Even the development of tolerance and withdrawals were propagated as signs of addiction. This is directly contrary to the textbook used by most psychiatrists and psychologists, the DSM V.  But this did not slow them down in the slightest.   I had seen these arguments made in courtrooms during my studies of physician prosecutions, and now I knew where they were coming from. Juries were being told that physicians had been willfully blind to something that existed only in the head of the testifying “expert,” who had been paid hundreds of thousands of dollars to be there. These statements should be called out as inconsistent with objective, evidence-based medical science.

And that brings me to a final point.  Some of these speakers and experts have received significant funding from two other sources that I find suspect.  The makers of buprenorphine, and the law firms engaged in opiate litigation.  The law firms have actually funded “grassroots” organizations that demonize any use of opioids in a manner that the most ardent alcohol prohibitionist from the early twentieth century would consider biased.  No less than Scientific American has called out one of these organizations for ignoring the clear evidence that reducing effective pain treatment and safe medication availability is dramatically increasing the overdose rate in America.

But, paraphrasing Mark Twain, it is hard to convince someone of the truth when they are paid to see the opposite.  I have hope that the tide will turn. A recent article in the New York Times documented a pain specialist’s difficulties getting treatment for her mother with pancreatic cancer, arguing that the DEA should stop being given free rein to regulate pain medicine. But just as quickly, a DEA-sponsored rebuttal was written, arguing that, despite the obvious falsity of the original argument, opioid-related deaths were from prescribed pain medications, and, as Cotton Mather would agree, the witch hunts must continue.