The Opioid Epidemic and New Ideas

You cannot turn on a television without seeing it. You can’t read a magazine or a newspaper without it being there. It is all the buzz, from Washington DC to Jefferson City to Camdenton City Hall. If you believe the hype, you are now convinced that there is an Opioid Epidemic.

Admittedly, there are patients who do not use their medication but sell it.  There are folks who use SOME of their pain medication but share it with others. And there are some who have it stolen from them – either the medication itself from their homes/cars/purses or the paper prescriptions themselves. Saddest of all is when dying cancer patients have it stolen from them by those who are caring for them.

But it may relieve you to know that this is a small percentage of all the folks who legitimately require pain medication to make it through another day of work, or simply another day or night. The majority of responsible patients appreciate what the medications mean to them – salvation from the kind of pain that depresses the soul and that sends them to the edge of the pit, even considering suicide. Right now, we have few weapons in the arsenal against chronic severe pain besides opioid pain medication, and when it is one’s only genuine weapon, one must reach for it.

In search of a better understanding of what pain really is, and how to address it, I have taken the step into an ancient world.  With my right foot still firmly planted in allopathic, modern Western medicine – the science and art I was taught in medical school, trained in during my residency training and have practiced for 15 years – I step lightly into the world of Eastern medicine and its 5,000-year-old practice and refinement. I found a course geared entirely to the Medical Doctor – physicians educated and trained like me – which integrates Western with Eastern medicine, also known as Traditional Chinese Medicine.

With our understanding of the Central Nervous System, the concept of meridians and neurotransmitters intermingles and all the cogs fit together to illustrate a beautiful “machine” that is the human body. This course started in April and runs through the end of November this year, and I have studied and learned from my laptop up to now. In July-August, I travel out of state for several intense days of practical hands-on learning. Because we don’t learn everything we need to know from a book or a lecture – we have to PRACTICE.

When I complete this course of training, I will be certified in the Traditional Chinese Medicine Acupuncture method. But I will be no ordinary acupuncturist – because I have the solid medical education and training behind me, with the Paul Harvey-esque “The Rest of The Story” understanding. My hope is that this rounding out of my knowledge will not only help me address the Opioid Epidemic by providing my members with a real alternative to narcotic pain medication, but also help similarly treat a multitude of other diseases and conditions.

I look forward to putting into practice all that I am learning. I hope that you – my members – will benefit from all the hard work involved in learning not only a new skill, but centuries of practice of an ancient art.

Propaganda?

Propaganda: noun: information, especially of a biased or misleading nature, used to promote or publicize a particular political cause or point of view.

The word “propaganda” did not initially have a negative connotation; the negative association with propaganda came about as the word was used extensively during World War II.

Today, propaganda is still widely used in business, politics and healthcare, and is something of which individuals need to be aware.

The true author of Propaganda was Edward Bernays (literally; the title of his book in 1928 was Propaganda.) By observing what was used during the First World War, Bernays outlined how to “regiment the public mind.”  This is the same man responsible for smoking among women. It wasn’t until Chesterfield applied his advertising techniques that women began smoking in numbers. Bernays was the master of using propaganda to sway entire populations to think a certain way, behave a certain way and—most assuredly—vote a certain way.

Just think of the today’s catch phrases used by media talking heads! While dining out with my sister, I actually got loud and argued with her, because she blurted out a summary of a political candidate that was sheer propaganda. I asked her why she thought that about this person; and honestly, she was so surprised at my outburst she couldn’t reply.  I accused her of being guilty of simple regurgitation of what she had heard others say. I made it clear that I was not a fan of this person myself, but I had become painfully aware of these subliminal messages that turn us all into thoughtless robots.

Advertisers use subtle propaganda all the time. Did you ever feel you just had to have a 50-cent corndog from Sonic? I even quoted the commercial when I took a bite and said, “There’s a hot dog in here!”

If you don’t drive a Lincoln you just aren’t as cool as Matthew McConaughey.  And what about my all-time favorite: “Ask your physician if (fill in the blank the name of medication) is right for you.”

We are manipulated at every turn—from the pulpit to the radio to television to newspaper. We are assaulted in the movies and television shows we watch.  I was watching a show the other day that is supposedly conservative. The family had just come home from attending church, and the matriarch was upset because the pastor confessed to having a problem with pornography addiction. It soon became obvious through subsequent conversation that everyone else in the household viewed pornography—every one but her. The subtle way they made this seem natural and all encompassing concerned me, because I realized that the writers of this episode were attempting to convince those who were watching that pornography is natural and all encompassing!

The little bit of time I watched (I turned it off once I realized the viewing audience, myself included, was being manipulated) I did not hear about how pornography contributes to human trafficking, or the impact on the lives of those in the industry.  The sex industry is rife with social concerns, but let’s promote it further by using a supposedly conservative sit-com to manipulate otherwise “sexually up-tight” Americans into thinking that “everyone does it”. Really?

That is misleading information to promote the idea that pornography is natural, everyone watches it and it’s no big deal. That is propaganda.

One would hope that the world of medicine would be immune to propaganda, but not so. Even the term “healthcare” is propaganda; it has molded people’s thinking more toward “health” than illness. However, physicians are trained to recognize and treat illness and disease.  We are also trained to treat individuals, not societies or populations.  But the concept of “healthcare” is more community based, more global, if you will.

The trend toward “health” as opposed to “illness” causes us to marginalize the diseased and concentrate on the healthy. If you want to create a society of only healthy individuals, to reduce the cost and burden of the few very unhealthy, you can use propaganda to change the opinion of an entire society.  For example, while recognizing that the concept of a “wounded warrior” will stir the empathy of most people, we marginalize these same veterans and they will die while waiting in line for their chance for treatment. Organizations like the Humane Society of the United States (HSUS) prey on the sympathy of people with these heart-wrenching advertisements, asking for money to help save the lives of dogs. But, they do not even believe in pet ownership, and actually destroyed animals that were orphaned from Hurricane Katrina instead of sending them on to be adopted!

These same subtle forms of propaganda are being used by our biggest organizations within the medical world and are working hard to manipulate physicians and patients alike into buying the concept of “healthcare” vs. medical care. Developing guidelines based on population statistics—and going beyond encouraging physicians to follow these same guidelines by actually tying physician compensation to the adherence of the guidelines—is one excellent way to lead physicians by the nose and get them to do things they ordinarily would not do.

How do you get people to give up their rights? By scaring them into feeling insecure. They will then clamor for more and more security. We will stand in line for hours to be pawed at and have intimate pictures taken of us in order to fly a couple of states away. We will get out of our cars and allow searches of our vehicles without a warrant, because we are afraid of being shot or incarcerated. We will continue to purchase online—in spite of having our identity stolen once or twice—because of convenience. We will allow our every move to be monitored, because we don’t want terrorists to blow up our schools and hospitals.

Do me a favor, get a copy of Enemy of the State and watch it.  I don’t care if you saw it when it came out in 1998. Watch it again. Watch V for Vendetta. See if you can find where propaganda was used against the people. Read Atlas Shrugged. Open your eyes to how we are being manipulated for most of our waking hours by all forms of media. Is there any subtle “nudging” in your television shows, your news programs, your book club books, your magazines, newspapers or in commercials? If you start looking for it, you will find it.

Start asking “why.” If someone tells you “Right to Work” is bad for Missouri, ask why. Then if someone else tells you it is good for Missouri, ask why. You may have to do some research.  Follow the money.  If the big money is being thrown into only one side of an issue, you should try to find out WHO and WHY.  Why did all the big insurance companies, big hospital systems and big physician groups enthusiastically support the Affordable Care Act? Follow the money, both going in AND going out. Why did Missouri lawmakers readily and easily agree to Anheuser Busch InBev’s supported legislation to allow them to put in coolers for package liquor sales? Follow the money, both going in AND going out.

I know; I’m conspiracy minded. I tell people this up front. I am used to name calling, since I am a Christian (originally a derision), a Methodist (again, originally a derision), a libertarian (“those people are plum crazy”) and a believer in the free market, EVEN IN MEDICINE!! The best way to get people to stop listening to those who buck the “status quo” is to marginalize them, call them names.  Please keep this in mind the next time someone says, “So-and-so? He’s (fill-in-the-blank).” Smile and recognize the propaganda machine is at work!

 

Demise of the Individual in Medicine

“I worship individuals for their highest possibilities as individuals, and I loathe humanity, for its failure to live up to these possibilities.” – Ayn Rand, “Anthem”

One of the most concerning trends in medicine I see is the movement away from individualism and toward collectivism.

This trend manifests in multiple ways in our medical institutions, arising as such creatures as Evidence-Based Medicine and the notorious use of the Bell Curve (http://statistics.about.com/od/HelpandTutorials/a/An-Introduction-To-The-Bell-Curve.htm) to apply population-based statistics to the treatment of individual patients. While these statistics may be useful for adopting guidelines—i.e. MOST people will have this experience with this drug—attempting to apply guidelines as hard and fast RULES in the medical sciences is rather disturbing.

Many consider ancient Greek physician Hippocrates to be the Father of Medicine, as he lived in the 4th century BC.  A close look at the Hippocratic Oath, which many medical students take upon graduating from medical school, shows the importance of the individual patient above and beyond the concerns of the collective—the community, the society or the State. http://www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html

While the original oath first upholds sacred the community of medical practitioners as a family, it goes on to state that treatment for the sick will never be given to intentionally harm, that is, “according to my ability and judgment, I will keep them from harm and injustice.”

We have embraced this to mean, “First, do no harm.” But when there is a clash between individual concerns and the public concerns, to whom shall the “no harm” be directed? I would fully expect the physician who works for a public health organization (or one with a Master of Public Health degree) to take the stand that the concerns for the public health outweigh that of any one individual. However, it is my belief that for me—as a primary care physician —the medical concerns of the individual are, well, PRIMARY.  If not the family physician, then who will be the advocate for the individual patient?

The Hippocratic Oath goes on: “Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.” Personally, I interpret this to mean: I will not murder. I will keep private things private and to myself. I won’t take advantage of my position for personal gain.

These are the basic tenants of medical ethics. After the atrocities of the Second World War in the 20th century, it is no surprise that the oath I took with my classmates in 1999 includes refraining from unethical experimentation. If you read about the things that have been done to people in the name of “science,” you wonder how any physician could be encouraged to do such things. Then you find that it was all for the sake of “the good of the People.” The information gained could improve the lives of the Public; therefore, it was OKAY to subject others (particularly those considered to be sub-human) to all manners of experimentation, since it was for the Public Good.

As a modern example, let’s consider the “statin” debate. It is generally accepted in medical circles that statin drugs reduce cholesterol and therefore reduce the incidence of heart disease. Do we truly have a method of preventing heart disease by treating cholesterol levels, or have such a large number of studies (often sponsored by pharmaceutical companies that are developing statin drugs) been performed on certain populations that are sure to show improvement in cholesterol levels? Then, those same certain populations can be followed to see if heart disease develops, in order to create a logic that says “Using a statin reduces heart disease.”

I have trained myself to look directly at the study and see who was excluded rather than who was included as study subjects. This tells me who cannot be considered for a favorable result regardless of the results of the study! Think about it this way: if those individuals were excluded from the study, the designers of the study knew that portion of the population would skew the results away from what they want the study to show.

To further illustrate this, we can go to “Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis” http://www.nejm.org/doi/full/10.1056/NEJMoa0912321#t=articleMethods, the CREST study. Scroll down to “Selection of Study Patients” and look at who was excluded from the study. Then please note the last line of the section: “The full eligibility criteria have been published elsewhere.” Why? Would the eligibility criteria be so exclusive for the study that it may render the study of little use? But no, surely this is only going to be helpful for vascular surgeons to be able to decide whether they need to scrape off plaque surgically (endarterectomy) or place a stent, right? But, if I wanted to know if my patient with carotid artery stenosis (plaque build-up in the carotid artery) should be considered for a stent or an endarterectomy, I would go to the footnote (see that little number 10 at the end of that section?) and read the full eligibility criteria. I would do this specifically TO SEE IF THE STUDY RESULTS WOULD APPLY TO MY INDIVIDUAL PATIENT. I cannot apply population-based statistics to my individual patient because my individual patient may fall out of that Bell Curve!

So, I click on the footnote, and it gives me two choices of where to get the entire article (Design of the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST).

I can rent the article to read for $6 (good for 48 whole hours!) I can pay $15 to read it on the cloud or pay $38 to read, print and/or save a PDF file—just to see the full eligibility criteria for the study! So, I rely on what the article in the New England Journal of Medicine (which surprisingly allows access to the full article for free online) tells me about eligibility. Finding the complete facts can be an arduous and expensive endeavor, which is why some physicians rely on drug reps for their information regarding the efficacy of drugs for certain medical end points.

So here we are with physicians having sales representatives tell us why their drug is best at preventing heart disease. But, what if the whole cholesterol theory—stay with me here—is also a medical “certainty” built on the statistics of a few studies that excludes what could be a large part of the population that a physician will be seeing? In other words, what if an entire “disease” could be “created” for which only certain drugs can help prevent or treat? Before I ask you to slip on your tin foil hat with me, realize that it is not so outlandish to suggest this as a possibility.  I nearly threw a drug rep out of my office once for even using the term Chronic Obesity as if it were a disease and not a condition of storing too much reserve energy. But since their drug product was created to address obesity, they need a Disease (with a capital D) with which to associate their product. I asked her how long a patient needed to be on the product and she said, “Oh this is for Chronic Obesity. They have to be on it forever.”

I refrained from explaining to her how the human body naturally works, because I knew she was simply regurgitating what she had been taught to say by her company. By the way…I don’t prescribe their drug!

My argument for having multiple blood pressure medications, even those that work the exact same way in the body, is that what may work for one patient may not work for another, or may have undesirable side effects in one patient and not in another. I have seen this even in the same drug families. Humans are truly snowflakes—the basics are the same, but there are little variations all over our bodies, and that is what we can SEE. There are untold individual variances, chemically and microscopically, which we can only imagine. With that much diversity at the cellular (and sub-cellular) level, imagine the vast variability at all levels at once when it comes to disease process and drug or nutrition intake!

But, as physicians we are supposed to stick to absolute guidelines and certain measuring tools to satisfy some lofty powers that be, guidelines that were established based on the same kind of studies as the CREST study that we looked at above, which has excluded some patients from the study??!!

This kind of “logic”, once one really thinks about it, is not consistent with what we were taught in medical school. We were taught that life is NOT composed of absolutes, but a vast amount of variance that means we can only give it our best guess as to what we should do (if anything) in any given circumstance.

As a direct primary care physician—one paid by the number of members DPC has, NOT the number of patients I see in a day—I do not have any Meaningless Use mandates from the federal government forcing me to follow guidelines.  I can tell you what the recommendations are, whether it is for the care of those with Diabetes Mellitus or for breast cancer screening; but, my pay is not tied to meeting certain bullet points in a bureaucrat’s mandated guidelines. Therefore, I will tell you the guidelines, but if I don’t think those guidelines necessarily apply to YOU, we will discuss our options. I do believe I need to know the guidelines, and I need to know the options; however, it is your decision since your body still belongs to you and no one else.

And, you can trust I’ll roll my eyes or argue in anger whenever anyone suggests I need to consider the good of the community/society/public/world over the good of YOU, the individual. I don’t WORK for the community, society or the public—I work for you, my patient.