42. The Iatrogenic Opioid Epidemic

April 29, 2017

For forty years I have been adamantly against the over-prescription of opioid pain medications: typically Percodan or Percocet. The generic name for the main ingredient of those medications is oxycodone. See: https://en.wikipedia.org/wiki/Oxycodone

With the rise of “pain clinics” in the 1990’s, physicians who believed, or pretended to believe, the myth heavily promoted by drug companies that opioids, when given for actual pain, would not addict the recipient, convinced the medical licensing boards in California and elsewhere that doctors as a rule were shamefully “under-treating” chronic pain patients. Acting upon that false narrative, those boards, in turn, chastised doctors for this purported “under-treatment”, and forced them to take special courses as part of their Continuing Education requirement, encouraging them to prescribe opioids for any claimed chronic pain, whether the source of the pain was or was not able to be demonstrated: whether the pain itself made any rational sense or had a medical explanation.

This movement, I believed then and I believe now, was closely allied with the politically liberal “legalize pot”, (“legalize everything”) permissive agenda. I, on the other hand, having believed my 1962 medical school pharmacology teachers on the topic of opioids, benzodiazepines and other addicting substances, and after enduring the frustration of trying to wean a couple of patients off Percodan originally prescribed by other practitioners, never again prescribed Percodan to any but hospitalized patients with very severe, acute pain. And never prescribed even codeine for more than two or three days.

That was my policy, but since I, as a family doctor, never actually had sole hospital responsibility for a patient with fracture or post-operative pain, such patients usually being under the care of the orthopedist or surgeon on the case, in practical terms it meant that I never again prescribed oxycodone in any form. To any patient coming to me demanding opiates, I offered to help them get off addicting drugs and on to non-addicting analgesic medications and physical modalities to reduce pain. None ever took me up on my offer.

Recently a friend, citing physician income figures alone, attempted to make the case that physicians generally were significantly motivated by money. I disagreed, citing the much lower ‘dollars per hour of work’ figure and the many other rewards for altruism. But to the extent that there are physicians who are essentially in it for the money, I have always suspected the “pain management” crowd, and those doctors who make a living prescribing methadone, buprenorphine and other opioids to heroin addicts in the name of what is called a “harm-reduction” strategy. Their theory being that it is better for addicts to take a legally prescribed oral narcotic paid for by the state than to rely upon street drugs injected with dirty needles.

As one often involved in group interventions and referral of alcoholics to 28-day treatment programs, in a specific practice setting that yielded a 96% recovery rate, I have always questioned the fact that “addiction maintenance” practices are not associated with programs or efforts to actually detox the patient and get him or her beyond the phase of actual addiction to the substance in question. It has always seemed to me that such “maintenance” programs were examples of what is called “enabling” behavior and benefitted mostly the prescribing doctors. Some might find that a harsh position, but as a recovering alcoholic and nicotine addict with 40-plus years of abstinence from both substances, I am quite convinced that actual recovery is possible, and that for a physician to give up on that option and switch to a maintenance or “harm reduction” strategy is disturbingly self-serving. If some doctors are that pessimistic about treating addictions themselves, if it is not for the money, why not practice some other branch of medicine? Then again people in the helping professions are often from backgrounds that breed codependency. So there’s that possibility.

Today we are living with the consequences of the ill-advised public health policy adopted by state medical licensing boards. The huge upswing in overdose deaths from prescriptions painkillers became undeniable, and medical licensing boards are now participating in the swing of the pendulum in the opposite direction. I predict that despite our best efforts, it will take twenty years to undo the harm that the “harm-reduction” ideology has wrought.

The following excerpt is from the newsletter of Arizona Senator John McCain and represents movement in the right direction.

As the dangerous opioid epidemic continues to grow and devastate communities across the country, it has never been more important to advance solutions that will stop the scourge of these addictive drugs at the root. One of the main causes for the alarming increase in drug overdoses in the U.S. is the over-prescription of highly addictive opioids, which have increased by 300 percent over the last 15 years. In fact, people who are addicted to prescription opioids are 40 times more likely to become addicted to heroin.

We need to stop addiction before it’s too late. That’s why I joined Senator Kirsten Gillibrand (D-NY) this month to introduce legislation that would combat opioid addiction and abuse by limiting the initial supply of opioid prescription for acute pain to seven days. Opioid addiction and abuse is commonly happening to those being treated for acute pain, such as a broken bone or wisdom tooth extraction effecting individuals as young as teens. This legislation is modeled after laws in several states, including Arizona and New York, and it builds off Governor Doug Ducey’s work last fall that directly tackles the root cause of over-prescription.

Veterans, many who continue to carry the wounds of war, are especially susceptible to over-medication of addictive opioids, which can often lead to suicide. Since 2001, the rate of veteran suicide has increased by 32 percent. After controlling for age and gender, this makes the risk of suicide 21 percent higher for veterans than the average U.S. adult. Since 2001, there has been a 259 percent increase in narcotics prescriptions. In the largest veteran populations, veterans die from accidental narcotic overdose at a 33 percent higher rate than the rest of the population.

I recently introduced the Veterans Overmedication Prevention Act to combat this problem by directing the VA to conduct an independent expert study on the deaths of all veterans being treated at the VA who died by suicide or drug overdose in the last five years. This review would ensure that the VA has accurate information about the relationship between veteran suicides and prescription medication.

Stopping the over-prescription of addictive opioids is critical to putting an end to this tragic epidemic. These pieces of legislation build on important efforts to end the tragedy that continues to claim far too many lives far too soon.


41. Regarding a University Course on “Truth in Communication”

April 28, 2017

Recently my college announced an on-line course for alums given by a leading professor on the topic of “Truth in Communication”.

Being an old guy I had some trouble figuring out how to enroll, given that it seemed to be making use of several of the social media I do not use. But I responded with what I thought was a post to the upcoming discussion site, in which I said this:

Scattered factoids:

The latest neurobiology suggests that in each human brain there is a function that could be called, “the storyteller”.  That part of the brain takes in a few bits of sensory information, adds it to a stew of memories and makes up a story of “what is going on around here” at this very moment.  This process has also been called “confabulation” and is perhaps most easily exemplified by what happens when we are waking up in a bedroom not our usual one. 

Say the bathroom light or the window are not where they are usually found.  The hypnopompic brain first makes note of that data, then searches its memory, remembers that we are on a trip and that we stopped at a motel, and tells us that we are in the Best Western in Santa Barbara… or wherever.

It is useful and usually in our best interests to have this information be accurate, or “true”.

Let’s assume our interactions with others may be collaborative or adversarial.  When collaborative,  others will probably intend to mislead us the least.  When adversarial,  they will probably attempt to mislead us the most, and in a direction which serves their needs rather than ours.

Therefore I suggest that to characterize the present era as “post-truth”, (as the course description and other sources have characterized the times in which we live), makes the unwarranted assumption that there was ever an era of “truth”.  Whereas I suggest that all those who wish to shape the behaviors and beliefs of others tell lies in order to make others act against their own self interest, or at least in the interest of the speaker.

When have we ever expected a politician to tell the truth?  The old one-liner goes, “If you can’t trust a used car salesman, who CAN you trust?”

I do suggest that whereas we had gone through a period when journalists self-imposed certain ethical standards upon themselves, that era has passed.  I have thought of the process as the Jerry Springerization of the news.  After the very popular reception of the Springer television format, wherein he invited disgusting people to come and have their family fights on live TV, all programming began to emulate that style, until now it is difficult to find a news broadcast that doesn’t feature violently opposed ideologues interrupting and yelling at one another.

Moreover, what used to be reports of events that have happened has become three seconds of that information followed by hours of oracular speculation about what might happen in the future.  When these speculations are presented as fact, as they often are, since no one can actually know the future, those statements are inevitably lies serving the ideological agendas of the presenters. 

To me it seems that that verbal conflicts based upon different predictions of the future, since they can never be resolved in their own terms but must resort to other factors, like anger, bullying and intimidation, are basically fighting presented in the guise of discussion, which they clearly are not.

I look forward to what promises to be a real discussion when this course begins.

AB ’54

(For I had responded good two weeks before the course was due to begin.)

A Response from a Presenter

The next day one of the course organizers wrote to me, saying:

Great to hear from you, and thanks for the interesting comment! I think you’re quite right that the general preoccupation with truth in politics and in the media is somewhat misplaced. Not in the sense that the obfuscation of truth in politics and the media doesn’t matter, because it obviously does, and it’s obviously changing in really problematic ways. But I say it’s misplaced because the role of truth in communication has never been unproblematic, as you suggest.

This is the ultimate thing that I think we’ll tackle in this course–not merely whether the media is telling us the truth, but even when you and I are talking to each other, how does truth enter into it?

Is there one truth that reflects reality and that our communications are based on when we’re trying to be truthful? If that’s the case, then when we’re trying to be truthful with each other, we’re trying to triangulate on some solid foundation that we both might be able to agree on.

Or are there separate truths based on our perceptions or feelings–one for you, and one for me? If it’s the latter, then isn’t even truthful communication a kind of “fighting,” … because we’re trying to impose our disparate truths on each other?

And those scenarios assume truthful communication: actors who think they know the truth and are trying to communicate it. Obviously it’s even more complicated if you’re not sure about what the truth is, but argue something anyway, or if you are trying to manipulate someone into believing something that you think is not true…

Looking forward to the class beginning as well!

To which I responded on the same day:

Thanks for your reply.  Nice to make your acquaintance. 

You ask:  “Or are there separate truths based on our perceptions or feelings–one for you, and one for me? If it’s the latter, then isn’t even truthful communication a kind of “fighting,” as you call it, because we’re trying to impose our disparate truths on each other?”

Yes, it is certainly easy to slip over the line, from sharing one’s personal “truth” to feeling one must persuade others to have the same point of view, forgetting that even in a debate it is not the opponent who must be convinced.  [con-vince … literally to conquer with argument]  It is the judges.

If one shares one’s personal viewpoint, never forgetting to preface or end it with, “in my experience, in my view, according to my observation, or IMHO”, and if one takes a deep breath and detaches from trying to effect a particular outcome, or if one says the Serenity Prayer, asking for the serenity to accept the things one cannot change, then in my experience the encounter remains a discussion and can avoid being any kind of fight. This, of course, is all…in my view! 😉

Some people, and perhaps all people sometimes, view human interactions as a zero-sum game.  They think if they acknowledge the other person is right, they themselves must be wrong.  Whereas if we each confabulate our separate realities, many opposing views may all be “right”.  Or perhaps none of them are.

In fact whenever someone claims to know the “truth” about anything especially in advance of or in the absence of compelling evidence, I suspect there is a game afoot to control others with it.


Upon reflection since that writing, I would now add the following:

In the general environment of community interactions there is probably always a competition to control group behavior, in which competitions the need to “know” (to guess most accurately) the future is perhaps the most powerful component. In oracular statements about what will happen next there is not even a remote possibility of knowing the “truth”. In the utter absence of any authority among coequal adults to know the future, speakers will nearly universally resort to tricking listeners into believing that they themselves have a special knowledge, or that they speak with the magical knowledge and the words of a higher authority. I offer all of the prophetic religions as prime examples of this phenomenon. Or, the Wizard of Oz!

For individuals it may be too frightening to be in the world and not know what is going to happen next. To imagine this feeling I think of a four-year-old alone in the wilderness. A child depends for his sanity on the reassurances of a parent. Adults, in whom that child still enjoys an inner existence, may imagine the words and reassurances of a parent no longer present, in order to stave off overwhelming fears of adverse consequences, up to and including that of experiencing death. Those imaginings may manifest themselves as a belief that their personally confabulated story about ‘what is going on around here’ is Actually True. And they may defend that Truth as if to be wrong is to die.

Not long ago I learned that Earnest Becker had developed something like this theory in a book called, “The Denial of Death”.


That was the story Becker confabulated about “What is going on around here?”

And all of this has been the story I have confabulated to answer the same question in the context of truth and lies.

An important question to ask might be why we confabulate this on-going series of answers to, “What is going on around here?”.

I think it is because we need to make decisions every moment about what to do next. Therefore we need to establish what for us is “real” at this moment and what is likely to happen in the next, depending upon our current choices.

In the early 1980’s, after entering into the state of prolonged bliss produced by a week-long contra-dance camp, I undertook a thousand-mile motorcycle trip south, down Highway I, along the cliffs over the ocean, to Santa Barbara for one last contra dance there before returning to work in the Bay Area. On the way back up the coast the day after the dance, I stopped unannounced and without plan at Esalen, the hippy-style, more or less Gestalt community in Big Sur. The young man on the gate regretted to inform me that absolutely no one was granted admission without having signed up for one of the week-long workshops.

He was a nice fellow and, in my blissful state, accepted that I could not enter, but sat resting astride my BMW while I asked him a few questions about the Institute. It was midday and there was no other traffic in or out. I think he must have been pleased to have a little company at his lonely post. After a few minutes he said, “You know, everyone is in the dining hall. Why don’t you just go in and have lunch before you drive on.”

Which I did. A lunch a young woman sat down next to me who turned out to be a staff member. We chatted and, knowing the story of how I came to be there, she suggested that I go with her to her next session before driving on, which was a class in Esalen Deep Massage. “Like Rolfing”, someone later explained, “except that Ida Rolf won’t let us use her name on it.”

Listening to the massage teacher describing the reasoning behind the efficacy of the technique: that the massage actually broke down the fascial adhesions between the back muscles, allowing the recipient to make the postural shifts attendant to the process of personal transformation. Thus, it was said, the massage facilitated the process of transformation, often with deep emotional feelings evidenced by weeping.

I felt myself stiffening in resistance to this “theory”. I had been a co-therapist in a Transactional Analysis group for four years and believed that people could indeed transform themselves with therapy, and that postural changes were clearly a part of that process, but I had also been a surgical first-assistant during back surgery on many occasions, and had literally separated sheets of back muscle by “blunt dissection” with my fingers. My mind was telling me that there was no possible way this could be done by massage from outside, through more than a half-centimeter of the thickest skin on the human body.

I could feel my brain blocking the words of the massage teacher. At that moment I made a decision. In order to hear the teacher without blocking, I mentally added, “IT IS AS IF….” in front of every statement, changing his every assertion into a simile in order to remind myself it was a metaphor.

I still had a problem with the painful nature of deep massage, suspicious that it was a form of abuse, but because I was able to voice that concern respectfully rather than as an accusation, the teacher assured me the massage was supposed to just approach, but not reach, the level of pain. At which I assented to become one of the test subjects and discovered it was not, after all, actually painful to me.

Then, somehow I was invited to enjoy the famed Esalen hot tubs, situated part way down the cliffs looking South over the sea. After which it was too late to drive on, and I was given dinner and a bunk for the night in one of the cabins. Now, thirty-five years on, I don’t even remember exactly how all that happened.

Awaking at about four in the morning, from a dream that I was back at dance camp in Mendocino, hearing our Seattle caller, Sandy Bradley, singing out, “Chain the LAY-dies!”, I could not regain sleep. So I got up and again climbed down the cliff trail to the hot tubs, where I soaked alone while watching the world become light.

There I experience a remarkable perceptual optical illusion.

As the sky and sea grew silvery-gray there was a deep Pacific swell from the south. The famed kelp beds produced dark blobs on the very slowly moving hills of water that marched in ranks towards the high cliffs where I sat in the hot spring water. Suddenly the rolling hills of water looked like ranges of Catskill foothills in winter, dotted with dark evergreen trees. I had hiked those mountains as a teen in high school. And for my mind it was, for a moment, difficult to turn the perceived image back into waves on the Pacific ocean three thousand miles and thirty years to the west of those mountains.

Once I had done so, I turned the image back and forth a few times, sea to mountains to sea to mountains. Eventually the light grew stronger, the color of the sea changed and the optical illusion was lost.

In the context of a discussion of “truth”, the trick the brain plays in the “Young Girl – Old Woman” illusion, and others like the mountains-waves illusion, further illustrates the idea of an individually confabulated reality.

young girl old woman

Which suggests that even when the intention is to convey the “truth”, that reality may differ from one person to the next. For myself, I find it convenient to accept this form of relativity by thinking of versions of the truth as metaphors, and easier to accept, remember and communicate that they are metaphorical if I mentally convert them into the more literal similes they represent.

As an allopathic physician used to thinking of my profession as evidence-based, it is easier to hear a chiropractic or acupuncture diagnosis without growing angry, if I preface it with, “It is as if…”. Of course the more difficult thing to accept is that allopathic medicine and indeed every scientific “fact” is also merely the most complete and consistent metaphor we are able to come up with at the moment.

It seems to me that if all is metaphor, even this essay, it is good to remember that all metaphors are provisional and not permanently true.  It is also good to remember that not all metaphors are equally accurate and useful, lest one slip into a state of complete moral and physical ambiguity.  And lest one should become the victim of the metaphors of others intent upon controlling those around them.