Wednesday, April 17, 2013

Doctor Arrogance

There are many reasons to end drug prohibition. The usual one's cited are eliminating the black markets, improving the purity and safety of drug dosages, reforming America's unconscionable system of mass incarceration and ending the violence and corruption endemic to producer and transit countries. There are numerous other examples, but there is one reason that is consistently overlooked.

Restoring the Honor to Pharmacists

The modern pharmacy profession is a pallid shade of its former glory. The responsibilities of the pharmacist has been largely subsumed by the doctor. It is doctors who now dole out drugs, pharmacists are now largely well educated pill counters and gatekeepers. The pharmacist is the last link on a long (and expensive) chain of events that separate drugs from the people who want to take them.

In the good old days before drug prohibition when an individual wanted drugs they consulted a pharmacist. The pharmacist was expected to be knowledgeable about the effects of the various drugs, knowing enough to recommend treatments for common ailments. Doctors were called to diagnose and treat more serious illnesses. Self-medication was an unstated assumption, and pharmacists played a key role in helping people make informed decisions.


The War on Drugs has Corrupted Medicine

By keeping certain drugs away from people who want to take them is a difficult task, one the police have had no lasting successes to date. But many drugs, especially opiates, are indispensable in medicine. For most people in the developed world there are only two sources for opiates, black market heroin, expensive and of dubious quality, or pharmaceutical opiates, pure and inexpensive (until they hit the black market where the value skyrockets). The appeal of getting one's drug supply legally, through a doctor, are obvious. So doctors must play two role, healer and detective. They must adequately treat pain while at the same time be on the lookout for malingerers (fakers). The fact that pain cannot be objectively measured, there is no scan or biochemical test to measure pain, only complicates things. The end result is that chronic pain is under-treated,     if treated at all. If an individual is label a "drug abuser" they often are ineligible for pain relief. Despite evidence that opiate addicts require higher dosages for effective analgesia, they are almost always given less. Apparently it is better to let an addict be in pain than to risk them feeling even a little good.

Drug addicts are the scapegoats of our modern age. Accordingly they are blamed for the fact that some chronic pain patients cannot get adequate treatment. Drug addicts however are among the most powerless members of society. They certainly do not have the power to keep drugs away from anybody. That power rests with doctors and government agencies like the FDA and DEA. Blaming addicts for the mistreatment of people in chronic pain may be popular, but it is incorrect.

People who use drugs see the acquisition and consumption of said drugs as a game. Not in the sense of a recreational game, but in the game theoretic sense of a series of goal-oriented, strategic interactions. For most opiate users their choices of supply are either an unreliable and price-inflated black market, or to see a doctor. Since doctor's are seldom accommodating when facing outright requests for narcotics, people employ subterfuge. Naturally doctors do not respond well to being lied to, and respond with hostility. An example of the venomous view of drug users was posted to a message board for medical students:

Yea, drug addicts are just filthy sub-humanoids who not only DO NOT deserve to be treated as a human being in help, but also DESERVE our undeniable rage and any afflictions that come across their path. I can't wait until the various anti-narcotic vaccinations make it out of clinical testing and into anyone who wants to go to public school.
Think about it like we are the Jews being persecuted by those Nazi-ass junkies.
I know that I am saying what everyone here is thinking, but are just too afraid to let their real opinions be known. Drug addiction is a disease worse than Hepatitis(ironic how most junkies get that too!) and just as contagious. We, the vanguard of future healthcare, must take an extreme position in order to truly accomplish what we have all desired: a quick and painful death for drug addicts.
Hyperbolic statements about "Nazi-ass junkies" aside, the lack of humanity of this would-be doctor would be shocking if it were directed at any other group. It could just as easily be homosexuals who "DO NOT deserved to be treated as human beings in help...but also DESERVE our undeniable rage and any afflictions that come across their path" or calls anti-homosexual vaccinations for grade school children. I have written about the stigmatizing language before. What is interesting is that this person views themselves as the "vanguard of healthcare" who must take an extreme position to eradicate the "contagious disease" of drug addiction. This person apparently thinks doctors should be both healers and drug warriors, two roles that are inimical to each other.

The Arrogance of Doctors: The God Complex
Some doctor's are said to suffer from a "God Complex", in which they assume they know their patient's needs better than the patient themselves. Many doctors labor under the delusion that they alone know how to heal. Oftentimes this arrogance extends to the entire person, the doctor knows their body and mind better than the individual himself or herself! The notion that someone may be self-medicating with opiates is dismissed out of hand. Here is another post on the same online board for medical students:
We are not depriving people of the pain relief they "need," rather we are not giving them addictive narcotics when it is not appropriate for them and will cause further health decline.
You say "need" but you have no idea what you "need." That is why you see a physician. You do have an idea what you "want," which is very different than a medical indication. You "want" to get high. You "need" to be safe and get healthy.
Using opioids out of a medical context is illegal, and highly dangerous. Self medication for mental disease is also highly dangerous and should not be attempted by patients.
Therefore, as physicians, we are fully opposed to junkies like you doing this.
We all prescribe opioids for legitimate uses, none of which include treating "mental ailments," nor the desire to meet the "wants" of our patients.
From this we can examine three claims:
1. People have no idea what they need, only physicians can make that determination. (People only know what they want)
2. Using Opioids outside of a medical context is illegal and highly dangerous
2. Self-medication for mental disease is also highly dangerous and should not be attempted by patients

To refute claim 1 we must first ask what gives a physician their authority. Physicians are expected to have completed certain educational requirements signified by the awarding of a medical degree and a license to practice from the government. And yet education alone cannot account for this incredible power physicians have to determine other's pharmacological need. After all a professor of pharmacology, who may know more than most physicians about the pharmacology of drugs, is ineligible for determining their own needs. Many drug users have no formal education, and yet are very knowledgeable about the pharmacology of the drugs they use. It is the license to practice medicine alone which gives doctors the power to determine the pharmacological needs of others. The control over drugs by the government is called pharmacracy, and for opiates the control is totalitarian.

Claim 2 states that using opiates outside of a narrow medical context is illegal and highly dangerous. There can be no argument that it is illegal. It may merely be pointed out that this was not always the case, and for most of the history of this country this was not the case. Using opiates may be dangerous, people do die of accidental overdoses, but is it highly dangerous?

One method of comparing the dangerousness of drugs is by comparing their therapeutic indexes. The therapeutic index is a ratio of lethal dose to therapeutic dose, larger numbers indicate safer drugs. For example alcohol, with a therapeutic index of 10, requires about ten times the dose that causes drunkenness to be lethal. The above image is from an article in American Scientist. While heroin is listed as the most lethal, it should be noted that the stated value is for intravenous route of administration. Oral morphine is not listed, but is probably similar to codeine. I have been looking for specific therapeutic index of opioids but have found widely diverting values. However, there is the synthetic opioid Sufentanil which is similar to fentanyl. It is extremely potent, but more importantly has an extremely high therapeutic index of approximately 25,000. This puts it near the top of the safest drugs listed.

If users had a choice of multiple opiates and synthetic opioids to choose from, self-medication would be no more dangerous than alcohol and in all probability much safer if options like Sufentanil or yet undiscovered opioids were made available. With the right information and pharmaceutical quality drugs of known dosage, the chance of an accidental overdose could be largely mitigated.

Claim 3 is similar to previous claims, though specific to dealing with self-medication for mental illness. Is self-medication for a mental illness highly dangerous? Should it not be attempted by patients?

This claim is too broad to refute completely, for example what mental illness and medication are we talking about? If the mental illness is depression and the medication marijuana, its hard to see that as being highly dangerous. But we are talking about opiates here, not marijuana. I have addressed the risks of using opiates relative to other drugs above. I see no reason why using opiates to treat one's own depression or pain would be more dangerous than using them "recreationally".

As a society we have been indoctrinated to believe that self-medication is wrong. Self-medication is pathologized as drug "abuse", both a symptom of a mental illness and a crime. I however, view self-medication as a fundamental human right: an extension of the right to be sovereign over our own bodies and minds. Unless there is a compelling case that a specific regime of self-medication will cause harm to others it should not be criminalized.

Why would doctors react so vociferously against exercising the right to medicate oneself? Concern for the health of the individual cannot completely explain this reaction. As the above quotes demonstrate, these particular doctors are not acting from concern, else they would support measures to make self-medication safer (ie harm reduction). These quotes represent a sense of vitriol directed toward the individual (hence the use of the word "junkie"). Doctors' are threatened by people who take control of their own health. If people do not need a doctor to heal themselves, doctors are robbed of both income and control. By controlling the supply of therapeutic drugs through a prescription system, supported by a criminal prohibition against entrepreneurs offering illicit healing ("drug pushers"), doctors are able to monopolize the practice of medicine.

Fortunately not all these future doctors are as ignorant, as the following post reveals.

You clearly haven't had to live live with severe pain or you would have no qualms about using the word "need" in this case. NSAIDs do not work for severe pain. Cannabinoids, substance P antagonists and the various other classes of analgesics that I know of aren't available so people with various types of pain have very few options. I would take becoming physically dependant on a drug over living my life in pain any day. My grandmother is constantly in pain and all the doctors prescribe her are aspirin and difene. She says the difene works but the side effects (such as stomach aches) outweigh the benefits.
You're clearly just another ignorant, box thinking medical practioner who is only capable of parroting off the things memorised in medical school rather than actually thinking logically about matters. I'm not a junkie, I don't use any drugs, I don't even drink coffee. I'm a chemistry student but I'm thinking of going to medical school after this degree and becoming a doctor because the world needs more doctors who are capable of thinking outside the box rather than blindly conforming to the consensus which is clearly profoundly flawed. Every doctor I have met so far seems to be incapable of thinking pharmacologically, but rather they only think in terms of what is commonly prescribed for what.
Since doctors don't help them, patients are willing to take the risks and attempt to self medicate and they should have the right to do so. You ignorant doctors assume the patients don't have the mental capabilities to find solutions for their own problems, solutions that actually work for them, as opposed to "solutions" that doctors think should work for them because its what they learned in medical school. You obviously have a very limited understanding of opioids. Using opioids out of a medical context isn't really that dangerous. Without considering drug interactions (i.e. serotonin syndrome in patients on SSRIs, additive sedation of patients on anxiolytics etc.), the main danger is risk of overdose which is something any semi intelligent individual should be able to avoid. IMO anyone who uses opioids (whether prescribed or not) should keep some naloxone nearby in case of emergency.
You say prescribing them for mental ailments is not a legitimate purpose. This is exactly what I mean by box thinking and the sheep/herd mentality. It doesn't matter to you what works and doesn't work, all that matters to you is whether something is commonly accepted. In other words, whether the rest of the herd is in accord with it. Cannabinoids aren't a medically accepted analgesic but that doesn't change the fact that they are safer and more effective than any of the analgesics commonly prescribed today. When I fractured my scaphoid, they had to operate and put pins in to hold the bones in place. They prescribed me dilaudid (hydromorphone) and it did absolutely nothing for me. It may work as an analgesic for others but it had absolutely no effect on me so I stopped taking it. I was in constant pain then a friend offered me some cannabis so I accepted his offer. The pain completely abated. This is an example of different people having different neurophysiology and consequently, benefitting from different substances. Opioids might work as analgesics for most people but not all people. Similarly SSRIs might work as antidepressants for some people but not all people.
More doctors like this fellow please.

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