The proposed advocacy for addicts provides an altruistic cover enabling the group to pursue legal, regulatory and healthcare public policy change on behalf of addiction treatment for self benefit.

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ASAM Weekly is a publication of the American Society of Addiction Medicine (ASAM) circulated by E-mail to “more than 25,00 addiction professionals” every Tuesday.  It provides timely news briefings of top stories related to addiction medicine. The current issue includes a  National Survey on Drug Use and Health study correlating substance use with suicidal ideation;  original research  suggesting a strong link between  alcohol use and”thwarted belonging”  ( wanting and needing to be with others being socially isolated ) with both homicidal and suicidal ideation in a group under community corrections supervision by the criminal justice system; a study of privately billed services looking at the economic impact of the opioid epidemic on the healthcare system (Fair Health White Paper) which found a 1000% increase in opioid related treatment and service costs between 2011 and 2014;  and an article written for the  Huffington Post entitled  “When ‘All or Nothing’ Means Life or Death”  that questions the abstinence based model that currently monopolizes addiction treatment in the United States which the author notes  “is not only harmful and killing people,” but also “defies much of what we know about addiction.”

In his weekly editorial Editor-in-Chief William Haning refers to prescription database finding that the number of opioid prescriptions written in Tennessee last year outnumbered the number of people in Tennessee.  He appropriately notes this should “stun the readership” as it should. He notes several other articles this week “remind us that most of the public is not terribly interested in whether somebody has an addiction”  or the socioeconomic impact of addiction. He states “the public really can’t be expected to care” is someone with a substance use disorder is using substance and may not even be “realistically expected to care very much” about those who recover.

“What they do and rightly care about,” Haning declares,  “is the outcome of substance usage” and the public “is much more impressed by and will react to the consequences, ” As consequences he points to the two articles concerning suicidal and homicidal ideation and a report concerning sexual assault and violence from the University of Wisconsin .  He goes on to state:  “It causes an understandable lack of sympathy when a group of illnesses imparts injury to others.”  He lists crime, trauma in the workplace, spread of infectious disease and impact of childhood development of the disordered family as additional outcomes or consequences.

Haning notes a dilemma for those in recovery–they want to advocate for others but do not want to draw attention to themselves as the attention is far different from a diabetic or parent of a child with muscular dystrophy pushing for increased research or approval of a new medication.  He points out a national organization advocating for the treatment of the mentally ill exists (NAMI) that is comprised largely of those being treated but  “no strong national equivalent exists for substance use disorder yet” with two “organized bodies” as exceptions:    “physicians who have themselves entered recovery (IDAA), and another, smaller body of physicians in recovery who are engaged in the treatment of SUDs” These “organized bodies” have generally been focused on “ensuring identification of and care of their colleagues and patients” but have more recently become involved in the “pursuit of public policy changes.”  

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Propoganda, Truth and Credibility

In   Propaganda: The Formation of Men’s Attitudes  Jacques Ellul discusses the underlying assumptions and ideology that give rise to propaganda and the structures and belief systems needed for propaganda to flourish.  Propagandists  move with an “assortment of soothing and easily digestible notions.”  He discusses how easy it is for most people to accept propaganda as the individual does not want information but only value judgments and preconceived positions.  On the surface Haning’s proposal is rational and seems like a good idea. Who could argue with it?

It is important to recognize what Haning is referring to.    IDAA is an acronym for International Doctors in Alcoholics Anonymous , an AA fellowship of more than 9500 doctors.  The organized body focused on ensuring “identification” of “colleagues” are the state physician health (basically employee assistance programs for doctors).  47 of them are under the management of the  Federation of State Physician Health Programs (FSPHP).  The organized body focused on “care” of “patients is a group called   Like Minded Docs (LMDs). Collectively these groups represent the physician health program model and it is being promoted as “gold standard addiction treatment” based on a 2009 study called the“PHP-blueprint”  that reported remarkable success rates (80%).  The  high success rate is attributed primarily to close linkage with 12-step programs and the use of “residential and outpatient treatment programs that were selected for their excellence.”

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Mechanics and Mentality

The “PHP-blueprint” is abstinence based and 12-step participation is mandatory.   Random frequent drug and alcohol testing is used with zero-tolerance. A positive test results in an out-of-state “PHP-approved” assessment center and concepts such as “potentially impairing illness” and “relapse without use” are accepted.  The core organizational structure includes the state PHP, commercial drug testing labs and a number of  out-of-state “PHP-approved” assessment and treatment centers.  The PHP’s have no regulation or oversight.  The testing, assessments and treatment are out -of-pocket cash only.The assessment and treatment centers have very little oversight and because the  commercial drug-testing labs use non-FDA approved laboratory developed tests (LDTs)  they are not regulated.  No agency exists to provide sanctions for faulty or even fraudulent testing.  No internal or external avenues of complaint exist.  It is essentially a closed system in which no outside opinion is acknowledged let alone addressed.    Transparency and accountability are absent. Due process is absent.   Every “PHP-approved” facility is represented by a Like-Minded Doc and many of the doctors involved in the drug-testing process are also on the list of LMDs.   It is a rigged system and explained  here.    Choice in assessment and treatment is removed and the “PHP-approved” facilities engage in “diagnosis rigging” and are willing to label people with diagnoses when they do not in fact meet the diagnostic criteria for that diagnosis.  Pervasive problems include:

–Labeling normal variations in behavior as pathological

–Failing to receive proper diagnosis and effective treatment in those who need it

–Forcing unneeded evaluations and treatments including forced committment

Pervasive and Serious Concerns

Physician Health Programs- More Harm Than Good?  was the first article critical of  PHPs. “Physician health programs under fire” was recently published in the British Medical Journal (BMJ). The lack of accountability and financial and ideological conflicts of interest are addressed.  Complaints include coercion,  threats, “diagnoses rigging,” lab fraud and false diagnoses to  to support unneeded treatment.    The physician health program model is a major factor in the current suicide epidemic in doctors.

Profit Motive and Plans for Expansion

In his Editorial Haning  mentions a “national organization for advocacy of treatment of the mentally ill” called NAMI and this stands for the  National Association of Mental Illness (NAMI). It is considered a pharmaceutically funded front-group founded by Abott Labs, Pfizer, Eli-Lilly and pharmaceutical manufacturers.  They all market drugs for mental illness.    Mother Jones reported  $11+ million over 5 years from Big Pharma, and an Eli Lilly executive directed operations from their headquarters..  A U.S. Senate investigation revealed Big Pharma contributed $23 million in a just two years and until forced by the Senate Finance Committee to identify its corporate donors  had refused to do so. The “Campaign to Stop the Stigma of Mental Illness”  was started by NAMI and the group claims one out of five adults will suffer some form of mental illness in their lifetime.    The system is designed to provide a seemingly altruistic agenda but is in actual fact driven and funded by groups who profit from labelling more people mentally ill.     It is, in fact, the very same business model as what we see here but the primary profiteers are not Big Pharma but Big Rehab -the multi-billion dollar drug and alcohol testing, assessment and treatment industry.images-4

What is planned is explicitly spelled out in the  ASAM White Paper on Drug Testing . This is a Trojan horse for expanding the “PHP-blueprint.”  The business mode is similar to the razor or printer model.  The razor or printer does not generate a profit, the razor and printer cartridge replacements do recurrently.  PHPs are simply employee assistance programs (EAPs). Selling the PHP (i.e replacing an existing EAP) does not turn a profit, the non-FDA approved drug and alcohol testing does (and the referrals to the “approved” assessment and treatment centers.    The New York Times reported that the size of the US drug-screening industry grew from $800 million in 2000 to $2 billion in 2013.

Infrastructure Already in Place 

The drug and alcohol assessment, treatment and testing organizations are already present To replace an EAP with the PHP model  it is only necessary to convince an employer or  administrative agency in charge of professional licensure.   If elected as public policy advocates for addiction treatment they will most assuredly be lobbying and working on state and federal laws and aligning themselves with licensing boards to remove due process and civil liberties by “medicalization”.  This could impact anyone from our elderly, to our military, pregnant women, nursing mothers and school children. It is a testing and treatment  Trojan Horse.   They will be pushing public policy to coerce people into treatment who do not need treatment.

screen-shot-2016-09-28-at-1-33-33-amCreating Bogus Risks of Danger

Linking patient harm to “impaired” doctors is one of the primary propaganda techniques used by the FSPHP to forward the assessment, testing and treatment agenda. Be creating fear in hospital administrators, medical boards and the public ( “The Junkie in the O.R.” ) This appeal to  consequences (argumentum ad consequentiam) is suggested by Haning in the editorial. He states the public will react to consequences such as crime, trauma in the workplace, spread of infectious disease and “impact of childhood development of the disordered family “as potential consequences. The PHP system uses a medical license as “leverage” but any other license or benefit provided by the state could be used in the same manner.   This is what is called “contingency management” and how this is done is discussed in the ASAM White Paper on Drug Testing.

FSPHP/FASAM/LMD

screen-shot-2016-09-29-at-7-11-01-amThe primary architects of this system can be found on a list of Fellows of the American Society of Addiction Medicine. The list can be seen  here and includes  G. Douglas Talbott,  Robert Dupont, and  Paul Earley whose contributions to the current paradigm I have detailed in previous posts.   The list also includes  Greg Skipper  who introduced the first non-FDA approved  laboratory developed test for alcohol and is currently promoting  Soberlink -another junk science gadget that is prominently advertised as the top header in the current issue of   ASAM Weekly.

The list of like-minded docs was taken down from the website several months ago. Below is a screenshot taken the week prior.  On this list are Dupont, Earley, Skipper and the medical director’s of every single “PHP-approved” assessment and treatment center and it must be a small world after all because if you look at this list it has the name “Bill Haning” on it.  You will also find him on the list of ASAM Fellows.

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The Proposed Expansion of “physician health programs” (PHPs)and the urgent need for a critical analysis of irrational and illegitimate authority

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Physician Health Programs  (PHPs) claimed “gold standard” for addiction treatment. “80% success rate” being used to promote “new paradigm” to other populations. 

1. National Physician Health Program Blueprint Study Publications List

2.  Setting the Standard for Recovery: Physicians’ Health Programs

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PHPs are essentially Employee Assistance Programs (EAPs)  for doctors.  The vast majority of people know little or nothing about Physician Health Programs (PHPs).

Physician Health Programs (PHPs) are being called  the “gold-standard” for EAPs.    Claims of unparalleled success are being used to promote PHPs to other populations as a “replicable model of recovery.”

Drs. Robert Dupont and Gregory Skipper are promoting PHPs as “A New Paradigm for Long-Term Recovery”  claiming an 80% success rate in doctors.

An article entitled “What Might Have Saved Philip Seymour Hoffman,” claims PHPs “ought to be considered models for our citizenry” and the “best evidence-based addiction treatment system we have going.”   The author repeats the 80% success rate for doctors and claims Philip Seymour Hoffman might still be alive if he had been treated using the PHP model.

The basis for these claims is a 2009 study published in the Journal of Substance Abuse Treatment entitled  Setting the Standard for Recovery: Physicians’ Health Programs and authored by Robert Dupont,  A. Thomas McLellan,  William White, Lisa Merlo and Mark Gold.

This  study is the cornerstone of the “PHP-blueprint.” It is the very  foundation on which everything else is based, a Magnum opus used to lay claim to supremacy that has been endlessly repeated and rehashed in a plethora of self-promotion and treatment community blandishment.

To date there has been no academic analysis of the “PHP-Blueprint.”    There has been no Cochrane type analysis or critical review.    There has been no opposition to its findings or conclusions which are paraded as fact and truth without challenge or question and there is a general lack of concern from those both within and outside the medical profession.


The Expansion of Physician Health Programs (PHPs) to Other Populations

1.  Although these programs claim to help doctors they may actually be harming many and contributing to suicide.

2.  The plan is to greatly expand these programs to other populations and you could be next.

In 2012 Robert Dupont delivered the keynote speech at the Drug and Alcohol Testing Industry Association annual conference and described a “new paradigm” for addiction and substance abuse treatment and proposed expansion of this paradigm to other populations including workplace, healthcare, and schools.

It is therefore critical that the “PHP-blueprint” be examined using critical reasoning and evidence base.   All of this needs to be assessed in terms of legitimacy and intent.

Lack of Evidence-Base and Conflicts of Interest

A  cursory  analysis of the study on which this success rate is based reveals very little evidence base.

The claim of 80% success rate in physicians is based on Setting the Standard for Recovery: Physicians’ Health Programs is unfounded.  The study is a poorly designed using a single data set (a sample of 904 physician patients consecutively admitted to 16 state PHP’s).

It  is non-randomized and non-blinded rendering the evidence for effectiveness of the PHP treatment model over any other treatment model (including no treatment) poor from a scientific perspective.  The study contains multiple flaws in both reasoning (type I and type II errors) and statistical analysis that render its conclusions invalid.

In addition the impact of undeclared but substantial financial conflicts-of-interest (including funding by drug testing and addiction treatment industries) and personal ideological biases (including personal 12-step recovery from addictions) in the authors of this study also needs to be considered.

Moreover the misdiagnosis and over-diagnosis of addiction in physicians in this paradigm  incentivized by lucrative self-referral dollars for expensive 90-day treatment programs is a significant factor.

False Endpoints and High Mortality Rate

The mean age of the 904 physicians was 44.1 years. They report that 24 of 102 physicians were transferred and lost to follow “left care with no apparent referral.”

What happened to them? These are physicians with multiple identifiers (state license, DEA, UPIN, etc) not transient drifters.

More importantly what happened to those 48 who were reported to the Medical Board for noncompliance and had their licenses revoked–that would be the critical time when this population would be at most risk for completing a suicide. That would be when hope was lost and the coerced physician, knowing that the fight was over, would take that step.

The outcomes they used were the last reported status of the PHP participant enrolled in the program.   Measuring success of program completion in doctors compared to the general population is meaningless as the short-term outcomes are quite different in terms of the external consequences imposed.   The consequence of not completing a PHP is the invariably career ending.    So what happened to the 24 of who “left care with no apparent referral,” the 85 who “voluntarily stopped or retired,” and the 48 who “involuntarily stopped or license revoked.”

Whether you leave a PHP voluntarily, involuntarily, or with no apparent referral it is the end game and your career is over.  Comparing this to other populations where the consequences of failing to complete the program are not so final is inappropriate.     Claiming superiority over programs with a 40% success rate is unfounded because for most of those people the consequences are not so final and may mean nothing more than an increase in testing frequency.

The big question is what happened to the 157 physicians who left or stopped?  How many of them killed themselves. With an average age of 44 there were  6 reported suicides 22 deaths, and another 157 no longer doctors.  I would venture to say the number of suicides is a lot higher than they claim.  But using the last recorded PHP status as the final outcome obfuscates this.

Due to the severity of the consequences a 20% failure rate is quite concerning. This is of particular concern because many doctors (if not most) monitored by PHPs are not addicts.

As noted above, PHPs are essentially Employee Assistance Programs (EAPs)  for doctors. Most EAPs, however, were developed in the presence of trade unions and other organizations working on behalf of the best interests of the employee. This collaborative effort led to EAPs that were more or less “organizationally just” with procedural fairness and transparency.

Imposed 12-step ideology and use of non-FDA Approved Drug and Alcohol Testing

No such organizations exist for doctors.   Due to the absence of oversight and accountability  PHPs have been able to use non-FDA approved laboratory developed tests of unknown validity on doctors without any opposition.

The distinction between professional and private life as a fundamental value of our society  and the importance of this boundary was also upheld by these groups.

In the PHP paradigm no procedural fairness or transparency exists and the boundary between professional and private life has eroded.

PHPs impose 12-step ideology on all doctors referred to these programs.   State Medical Boards  enforce this in violation of the Establishment Clause of the 1st Amendment yet there is little recourse for doctors as they are threatened with non-compliance and loss of licensure.

Selling the PHP Paradigm

The use of 12-step  is most likely not ideologically driven but profit driven.

Abstinence based 12-step programs justify the use of frequent drug and alcohol testing with ongoing lifelong assessment and treatment.    As with drug-courts,  PHPs provide a lucrative model to the drug and alcohol testing, assessment and treatment industry.

The plan to expand this to other populations is outlined in the ASAM White Paper.

This concerns all of us.  The first step needs to be a critical appraisal of  Setting the Standard for Recovery: Physicians’ Health Programs,  the foundation of their claims of an 80% success rate and a conflict-of-interest analysis of its authors.  The legitimacy of the study and its claims needs to be questioned.

It does not take a Cochrane review to see that the emperor has no clothes.  This is not difficult. It is straightforward and simple.

As an illegitimate and irrational authority it is necessary that this opinion remain unchallenged. We need to challenge it.

Historical, political, economic and social analysis reveals that the “PHP-blueprint” is a false-construct built on circumnavigation and obfuscation.  An evidence-based scrutiny of the literature would reveal it to be invalid and of little probative value.

But if  nobody speaks up it is inevitable that they will expand the “PHP blueprint”  to other employee assistance programs and schools.

This is not just about doctors.  You too are at risk for coercion, control, conformity and forced adherence to a  lifetime of abstinence and 12-step indoctrination and if you do not speak up now it won’t be a risk but a certainty.

Request Medical School Administrators Question PHP Authority to Prevent Future Medical Profession Brain Drain

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Physician Health Programs (PHPs) now targeting medical students–More sheep for the slaughter

The attached article entitled “Medical school drug testing is a moral and scientific failure” opposes testing medical students for drugs and alcohol but things are going to get a whole lot worse.

In the past six-months I have been contacted by an increasing number of  medical students searching for help after being  trapped in quagmire of their state physician health program  (PHP).   Each of them had either been referred to a “PHP-approved” assessment center or had already had an evaluation recommending inpatient treatment.

Some of these students were subjected to non-FDA approved laboratory developed tests including hair testing for marijuana metabolites and the  alcohol  biomarker EtG.  These typeof tests can detect substances that were used days, weeks and even months prior to testing.

Medical students and physicians are just as likely to have experimented with illicit substances in their lifetimes as their age and gender matched peers.1

Although medical students as a group drink slightly more alcohol than the general population, the pattern and prevalence of alcohol, dependence is consistent with their age mates in the general population.1 2

Like it or not recreational and experimental drug use is widespread in young adults and most of them “grow out of it” and the 21st Amendment repealed the Volstead Act in 1933.  Alcohol is legal and those that can handle it have a right to a round of beers after a long day or imbibe a cocktail with a dinner date.  But according to the prohibitionist profiteers and moral preeners any drug or alcohol use is a sign of “potentially impairing illness” that must be addressed and treated early to prevent an inexorable slide into a chronic relapsing brain disease and abstinence and lifelong adherence to the principles 12-step spirituality are the only way to do so.

An old joke asks “How does a doctor define an alcoholic?”  Answer–“anybody who drinks more than he does.”   How does a PHP define an alcoholic?  Answer –anybody who walks through the front door.

In reality, a zero-tolerance paradigm utilizing this type of testing would be ruinous. With recreational and experimental drug use common in young adults a profession that refuses to accept anyone who tests positive for drugs will exclude large numbers of brilliant, talented individuals. Dismissing highly talented people in medicine for what might be a one-off recreational non problematic drug experience would retard its advance.

The use of these non-FDA approved tests of unknown validity should not be allowed to begin with but there needs to be a concerted direct attack on their use on medical students or the brain-drain on the profession will bring it back to the dark ages.  The ASAM White Paper on Drug Testing proposes imposing this system with mandatory drug testing by the healthcare system from childhood to old age.  College loans are proposed as “leverage” for college students in this “contingency management” paradigm so a lot of promising students could be weeded out before even applying to medical school.  Forget GPA and MCATS as the primary criteria for medical school admission will be sobriety and clean urine screens..

Diagnosing disease without meeting the diagnostic criteria for that disease.

None of the students who contacted me seemed to fit the diagnostic criteria for the diagnosis given to them stories which were articulate, detailed and sincere.   All cases involved either a naive mistake or isolated incident.

One student made the disastrous revelation to a PHP director who had just given a class lecture that she had smoked marijuana with her high school friends in her home state of Colorado.   She was then called in by the PHP and referred for an evaluation at an out of state facility where she was diagnosed with “marijuana dependence” based on a positive low level THC metabolite on a hair follicle test.  She was told she was in denial and inpatient treatment was recommended.  Although she admitted to occasional weekend marijuana use there were absolutely no problems in any realm of her life. It is self-evident that impairment due to drugs or alcohol impacting someones capacity to work or function needs to be addressed but the penalty imposed on her for her private behavior was to end her career in medicine before it even started.  The medical school administration mandated she either complete the treatment required by the PHP or she would not be able to enroll the following semester and not being able to come up with the up-front out-of-pocket cost for treatment she was not able to return to the medical school and has decided to pursue a different career.

Another student was anonymously reported to the PHP for smoking marijuana at a weekend party which resulted in a similar assessment and recommendation for inpatient treatment.  After spending 3 months at a facility in Alabama he is now under monitoring contract with his PHP but returned to school.

Healthy student asks for help in his organizational skills–ends up with a psychiatric and substance abuse diagnosis

After reading an advertisement in the state medical society newsletter promoting work-life balance a second-year medical student contacted his state PHP to obtain advice on his problem with “procrastination.”    Classes and working part time in the endocrinology lab left him with little time and he found himself slacking off on his exercise routine and burning the midnight oil before test nights.  He told the PHP director about his history of depression after his father died immediately before his freshman year at college. That October he became overwhelmed with sadness and missed his dad and hometown.  He sought help from the campus physician who prescribed prozac which was discontinued in a years time without return of any symptoms.

Realizing there were no classes in work-life balance but only a support group for “burnout” the student declined the PHP directors offer of an assessment of his “mental health.”  Much to his surprise he was called in the following week by a medical school administrator and told that the PHP was requiring an assessment at one of two out of state “PHP-approved” assessment centers in Lawrence Kansas.  He was at first confused at the nonsense he was hearing and then became indignant  at the nonsensical and illogical request without rhyme or reason and the betrayal of trust and ethics.  “Surely this must be a HIPPA violation.”   He obtained an outside consultation from a psychiatrist and contacted the campus physician who confirmed his diagnosis was acute situational depression and bereavement but the PHP disregarded the information.  He bartered for a local evaluation but this was refused.  He arranged for the 96-hour assessment in  Kansas.  His mother paid the requisite out-of-pocket up-front $4,500.00 to the facility and  she told him not to worry as his life would get back to normal after they confirmed he had no psychological problems.  “Dysthymia, Major depressive disorder, severe, in remission and alcohol use disorder” were given as diagnoses.  “Alcohol use disorder” was based on a hair test for EtG which was the result of his drinking an occasional beer or two with friends after school and on the weekends.  He was told  he may be “self-medicating” and playing “Russian roulette” given his history of depression.  Recommendations included inpatient treatment followed by a “structured aftercare program” of abstinence and monitoring by for alcohol and drugs of abuse.  Forced to sign a contract with the PHP he was understandably upset at the serious and unfounded sequelae that was the result of asking for help.

Another fourth-year student got into a bit of a shoving match with his buddy at the bar on a Saturday night and was reported  to his PHP anonymously.  He is awaiting evaluation.

This brings up another potential problem–sham peer review. As PHPs accept anonymous referrals what is in place to prevent inappropriate referrals based on removing a competitor and improving your academic standing.

A legitimately prescribed stimulant for ADHD bought a third year student into a PHP contract. He was  forced to discontinue the medication prescribed by a psychiatrist specializing in childhood ADHD by a family practitioner in “recovery” from abusing intravenous fentanyl who had been monitored by the PHP himself for ten years then became medical director after getting board certified as an addiction medicine specialist.

This student got 99th percentile across the Board on his MCATs and may one day cure cancer but now faces an uncertain future as he recently got a positive EtG on a urine test and they are currently “sorting this out.”

The most bizarre story was from a student who sought help for sleep troubles after reading about the PHP as a referral source. He subsequently saw a sleep-specialist and was diagnosed with an oversized uvula which was surgically corrected.  His sleep troubles improved but his troubles with the PHP remained.  A triathlete and excellent student the PHP determined he had a “thought disorder” and discussions of “schizophrenia” were entertained by the PHP and they recommended an out of state evaluation at one of the three gulags used by the FSPHP for  “disruptive physician”  and behavioral exams–Vanderbilt, Acumen and the Professional Renewal Center.  All of these facilities come with a guaranteed diagnosis.   Polygraphs and unvalidated neuropsychological instruments designed to detect “character defects”  cast a pretty wide net.

Question FSPHP with direct questions to undermine a “culture of professionalism.

It is important that medical school administrators refuse to engage in  blind deference to the authority of the state PHP.  Authority must always be questioned and to not do so is irresponsible.  Unquestioning allegiance to an authority does not comport with the history of the medical profession or science.  Faith in institutions demands mass adherence to faith in that authority and direct challenges to the status quo are needed to undermine that faith.   They have bamboozled the medical boards into implementing bad policy, approving bad science and making bad decisions.  They have duped state legal authorities into deference to their expertise and integrity under the notion that questioning these attributes undermines a culture of professionalism.  Fact of the matter is they have no expertise, no integrity and no professionalism.

PHPs have been contaminated with an outside influence and support an agenda that has nothing to do with protecting the public or helping medical students.  They are an illegitimate authority that has become an irrational authority and their recommendations mandate direct answers and justification.

If the PHP has concerns about a student then the first step should be to obtain an independent second opinion.  PHPs discourage second these second opinions and disregard all outside expert opinion no matter how well qualified and experienced that expert is.  Anyone outside this brood of addiction addicts is scoffed at as biased or unenlightened to the simplistic belief system with which they have contaminated the medical profession.     Look into the assessment centers to which they are mandating referral.  Ask what qualitative factors and quantitative measurements were used to approve that facility and why no one in Massachusetts has the ability come to a competent diagnosis.   The yarn that doctors and medical student have an ability to dissemble and appear normal while harboring a “potentially impairing condition” is one of the medical urban legends they started.  Ask to see the evidence base.  There is none and it defies common sense, logic and science.

An increasingly bright light is being shed towards the malfunctions and corrupt practices of this unaccountable confederacy of “authorities” and at some point soon their jig will inevitably be up.     In the interim, if you are referred to a PHP it would be a good idea obtain independent lab tests and two second opinions.  Although the PHP will disregard this documentation it would be wise to obtain it to prove both your normality and the discrepancy between your independent evaluation results and the cherry-picked pulled out of a hat multiple diagnoses confabulated and misrepresented by the PHP.

  1. Hughes PH, Brandenburg N, Baldwin DC, Jr., et al. Prevalence of substance use among US physicians. JAMA : the journal of the American Medical Association. May 6 1992;267(17):2333-2339.
  2. Flaherty JA, Richman JA. Substance use and addiction among medical students, residents, and physicians. The Psychiatric clinics of North America. Mar 1993;16(1):189-197.

 

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Medical school drug testing is a moral and scientific failure
ANONYMOUS | EDUCATION | MAY 11, 2014

Before the 1980s, drug testing was uncommon. It was widely viewed as an invasion of privacy and an infringement on fourth amendment rights. Today, a medical student is likely to be drug tested before entering medical school, before clinical rotations, and/or before residency. If preventing drug use among medical students is the goal of these tests, they have failed miserably. Urinalysis drug tests are ineffective. But more importantly, they are immoral.

Drug tests are ineffective for two reasons. First, they basically just test for marijuana. A 10 panel urinalysis technically tests for 10 different drugs, but marijuana is one of the only drugs that can be detected for more than 30 days. Cocaine can be detected for 4 days. Amphetamine, methamphetamine, ecstasy, heroin, and codeine all can be detected in urine for only 2 days. This means that a user of drugs far more dangerous than marijuana needs to abstain for just a couple of days. Psilocybin mushrooms, as well as several other mind-altering drugs, are not tested for at all.

For a marijuana user, a drug test might seem like a nightmare. But here we arrive at the second reason why drug tests are ineffective, they are easily beaten. A marijuana user may choose to drink a lot of water before his drug test to dilute his urine. Alternatively, he may choose to use a friend’s urine who he knows does not use marijuana. Either one of these options might work. But fortunately for such a marijuana user, there is another option that is essentially risk free, synthetic urine. There are several companies that make synthetic urine capable of beating drug tests. The word on the Internet is that Quick Fix is a safe bet. I personally know some people who would agree. At just $30 for a bottle, it looks like the drug test is no match for the free market.

Do not just take my word for it though. In 2003, the University of Michigan conducted a study on the effectiveness of drug testing students. From nearly 900 schools, the study found that drug testing, whether routine, random, or based on suspicion, had no measurable effect on drug use among students. Put simply, drug testing accomplishes nothing.

The most important concern I have about drug testing medical students is a moral one. Regardless of their effectiveness, or ineffectiveness, the endgame of drug testing is to prevent drug users from becoming doctors. Users, not addicts; and there is a big difference. A marijuana user might use on weekends or at night to relax, much like an alcohol user. A marijuana addict, although rare, is the type of person who might show up to important occasions intoxicated. The statistics on marijuana addiction vary. They usually show that less than 10% of users become addicts, but they always show that alcohol users have higher rates of addiction. A urinalysis detects alcohol for no more than 12 hours after use. This means that medical students who use alcohol are more likely to be addicted, and they face basically no risk of failing a drug test.

Should we be worried about medical students being drunk in clinical settings? Of course. And we should also be worried about medical students being high in clinical settings. Intoxication could be disastrous and it needs to be prevented. The good news is that this is done naturally. It is highly unlikely to find medical students who are addicts of marijuana, alcohol, or any mind-altering drug. I believe it is safe to say that the rigor of medical school itself prevents drug addicts from becoming doctors. There are, however, drug users who will make it into medical school or other rigorous scientific careers. Actually, many of them thrive. Richard Feynman, Kary Mullis, and Francis Crick used marijuana and LSD, Carl Sagan used marijuana, and Oliver Sacks used several illicit drugs. When drug tests are required for every medical student, the casual drug user, no matter how much potential he has, is bullied for no reason. The potentially dangerous drug addict has already been weeded out long ago.

Medical school is supposed to be based on science. The science shows that drug testing does not work. If it did work, then many great scientists would have been removed from their professions. These facts alone should be enough to settle the issue, but it is important to look at two more moral objections we should all have.

First, drug tests are not free. Before entering medical school, I paid about $30 for one. This does not sound like much. But charging students even one penny is unacceptable, for there is not even a fraction of a penny in benefit from these tests. The nearest drug testing facility for me was a 20 minute drive from my house. I could have driven anywhere for 20 minutes and just handed $30 to any random person. Surely, that $30 would bring more value to society than $30 wasted on a drug test. Imagine if a police officer searched a person’s car for drugs against his will, found none, and then charged this person $30. That is the reality of drug testing.

Second, drug tests are an invasion of privacy. Medical students should not be forced to prove their innocence. This creates a guilty until proven innocent environment. It immediately creates resentment among students, and rightfully so. Furthermore, what about people with paruresis? The International Paruresis Association estimates that 7% of people suffer from this condition, also known as shy bladder. Type “paruresis drug test” into a search engine and spend some time reading through the horror stories that are shared. These people suffer from a medical condition, and of all places, their medical school is completely inconsiderate.

Drug testing is a moral and scientific failure. Medical schools should be too embarrassed to take part in such nonsense.

The author is an anonymous medical student who blogs at unchainedmedical.
TAGGED AS: MEDICAL SCHOOL

Why are we tolerating the use of junk science against those in the medical profession? A direct question that begs for a direct answer.

 “That everyone shall exert himself in that state of life in which he is placed, to practice true humanity towards his fellow men, on that depends the future of mankind.” – Albert Schweitzer 
“By and by never comes” –St Augustine

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“A day’s impact is better than a month of dead pull”-Justice Oliver Wendell Holmes, Jr.

 I am looking for a few honest and credible statisticians, biostatisticians or epidemiologists who want to make a difference in the spirit  of service and helping others.  I can’t pay you but you would be combating injustice, corruption and dishonesty.   You would be doing your part in helping the Medical Profession, honest and decent doctors, our country and  perhaps our future.  

It is only a few public policy steps and minor changes in state regulatory statutes before what is described in the ASAM White Paper on Drug Testing comes to fruition.  Before we know it the Drug and Alcohol Testing Industries “New Paradigm” as described here by Robert Dupont will be ushered in as it did with doctors; not with a bang but a whimper.  From the ASAM white Paper:

“THIS WHITE PAPER ENCOURAGES WIDER AND “SMARTER” USE OF DRUG TESTING WITHIN THE PRACTICE OF MEDICINE AND, BEYOND THAT,BROADLY WITHIN AMERICAN SOCIETY. SMARTER DRUG TESTING MEANS INCREASED USE OF RANDOM TESTING* RATHER THAN THE MORE COMMON SCHEDULED TESTING,* AND IT MEANS TESTING NOT ONLY URINE BUT ALSO OTHER MATRICES SUCH AS BLOOD, ORAL FLUID (SALIVA), HAIR, NAILS, SWEAT AND BREATH WHEN THOSE MATRICES MATCH THE INTENDED ASSESSMENT PROCESS. IN ADDITION, SMARTER TESTING MEANS TESTING BASED UPON CLINICAL INDICATION FOR A BROAD AND ROTATING PANEL OF DRUGS RATHER THAN ONLY TESTING FOR THE TRADITIONAL FIVE-DRUG PANEL.”

To prevent this future drug testing dystopia, that includes testing schoolchildren, we need to take a step back and analyze the reliability and credibility of the “evidence-base” behind these multiple non-FDA approved forensic drug and alcohol tests and testing devices the ASAM proposes be used on the population at large utilizing the Medical Profession as a urine collection agency and bypassing forensic drug testing protocol by calling this “evaluation” and treatment rather than “monitoring” and punishment. New definitions, loopholes, secrecy and subterfuge are the bread and butter of these prohibitionist profiteers.

Amazingly, there has been no Academic review of these tests, let alone a Cochrane type critical analysis.  It is essentially untapped territory.  In addition there has been no Institute of Medicine type Conflict of Interest Analysis.  And that is why I am asking for help from statisticians, biostatisticians and epidemiologists.  The task would entail a review of the literature prior to the introduction of these tests for evidence base of forensic applicability (there essentially is none) and a review of the literature peri-and post marketing of these devices to assess the reliability and credibility of the underlying methodology and ascertain the evidence-base.  The goal would be publication in both academic journals and presentation to the general public through media publication with the assistance of investigative journalists and other writers. The goal is to get the truth out about these tests and allow both the medial profession and public at large to awaken to the menace this presents to medicine, our society and our future.

 Lack of Evidence-Base, Bias and Conflicts of Interest:  Making the Data Fit the Hypothesis

I am no epidemiologist or statistician but as with pornography I know junk-science when I see it.  Almost all of these tests were introduced with little or no evidence-base and, as with most of their endeavors, they did it below board via loopholes and cutting corners.

The overwhelming majority of papers are small, methodologically flawed, non-randomized, non-blinded  retrospective studies in that appear to make the data fit the hypothesis.   The authors can invariably be linked to those profiting from the tests of the testing process ( the patent holder, doctors associated with the drug testing labs, ASAM or FSPHP, Robert Dupont, Greg Skipper, etc.)

 

Ethyl Glucuronide (EtG) was introduced in 1999 as a biomarker for alcohol consumption,1 and was subsequently suggested as a tool to monitor health professionals by Dr. Gregory Skipper because of its high sensitivity to ethanol ingestion.2   

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Described as the  “innovator of EtG as an alcohol biomarker,” Skipper and  Friedrich Wurst,  “convinced” NMS labs in Pennsylvania “to start performing EtG testing in 2002.

The study most often cited as 100% proof that there is 100% accuracy in EtG testing proving alcohol consumption involved a mere 35 forensic psychiatric inpatients in Germany that was published in 2003.3  

Shortly thereafter the Physician Health Programs began using it in monitoring doctors and other professional monitoring programs soon followed.

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Screen Shot 2014-11-29 at 5.16.18 PMLaboratory Developed Tests -A Loophole to Avoid FDA Approval and Accountability

Up until the birth of the EtG tests used for forensic drug and alcohol monitoring had to go through the arduous, expensive and necessary FDA approval process.   The LDT pathway was designed to develop simple tests with little risk that have  low market potential (i;e. the cost of the normal FDA approval process would prohibit them from coming to market).  The LDT pathway was designed to improve patient care and help improve diagnosis and treatment. It was not designed for forensic tests.  LDT approval does not require in vivo testing.  It is essentially an honor system and to develop an LDT it is not even necessary to prove that the test is actually testing what it is purportedly testing for (validity).

So with little to no evidence base they introduced the EtG, had it developed and marketed as a LDT in collusion with unscrupulous labs, and then began using it on physicians being monitored by State PHPs. This then spread to other monitoring organizations in which there was a large power-differential between those ordering the tests and those being tested (criminal-justice, other professional monitoring programs).  These biomarkers have never been used in Federal Drug Testing, SAMHSA approved, DOT, and other organizations where unions or other organizations are present and looking out for the best interests of those being tested.

Another example of how this group removes accountability.  There has been essentially no oversight or regulation of LDTs.  Although there was a recent push for regulation of these tests the Drug and Alcohol Testing Industry Association lobby made sure that forensic tests would be exempt.

They then began publishing “research” on the EtG using the physicians being monitored as subjects. Many of the studies promoting the EtG and other biomarkers can be found  in  Journals that are linked to organizations that are linked to AA and were organized to educate the medical community.

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These small, methodologically flawed studies amount to little more than opinion pieces but   This “evidence-base” is predominantly in biased journals published by biased medical “societies.  
The EtG was subsequently found to be so sensitive that it could measure incidental exposure to alcohol in foods, over the counter cold medications, mouthwash4,5, hand sanitizer gel6, nonalcoholic beer7, and nonalcoholic wine.8  Sauerkraut and bananas have even been shown to cause positive EtG levels.9
The United States Substance Abuse and Mental Health Services Administration warned against using a positive EtG as primary or sole evidence of drinking for disciplinary or legal action.10  The Wall Street Journal in 2006 reported the problems with the EtG to the general public.11   
Screen Shot 2014-03-23 at 10.45.36 PMAs any rational authority would do, the majority of monitoring agencies abandoned the EtG after these flaws were revealed. The PHPs did not.  They continued to use the EtG on doctors uninterruptedly by telling them to avoid any products that could potentially contain alcohol; a ubiquitous substance in the environment. Since that time they have justified and rationalized (EtG)2,12 13  use by sequentially raising cutoff levels from 100 to 250 to 500 to 1000 to 2000 to now unknown and adding other LDTs as “confirmation tests such as Ethyl Sulfate (EtS)14,15 Phosphatidyl-Ethanol ( Peth)16 17 and other devices such as the Subcutaneous Remote Alcohol Monitoring Bracelet (SCRAM) and, their newest device the Cellular Photo Digital Breathalyzer (CPDB) that has recently been launched, just like the EtG Screen Shot 2014-02-23 at 10.00.22 PMwith little to no evidence base other than a pilot study done by Greg Skipper and Robert Dupont.18 
A  2013 article published in an ASAM incubated journal Alcoholism: Clinical and Experimental Research promotes the Phosphatidyl-ethanol (PEth ) test to confirm drinking.16  The study was done on physicians being monitored by the Alabama Physician Health Program who tested positive for EtG/EtS alcohol biomarkers. It is co-authored by Robert Dupont, Greg Skipper, and Friedrich Wurst and involved 18 subjects who tested positive for EtG/EtS of whom 7 claimed they did not drink.  After finding that 5 of the 7 tested negative for PEth they concluded that “positive PEth testing following positive EtG/EtS results confirms recent drinking.  Hard to wrap your head around the science in that one.Screen Shot 2014-04-30 at 1.06.53 PMSkipper is also using both Scram ankle bracelets and the CPDB monitoring in pilots in the Human Interventional Motivational Study (HIMS) Program that was developed in 2009 to “identify, treat and, eventually, re-certify airline pilots with substance abuse problems. 
 
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The Cochrane Collaboration does systematic reviews of the literature using conscientious, explicit, and judicious criteria to in order to produce and disseminate only high quality and evidenced based health care, exclude bias, and enhance transparency. The Cochrane database is a current and evolving database that includes the accuracy of diagnostic tests and is internationally recognized as the standard in evidence based health care.  This benchmark for evidence based health care and systematic reviews, records just 5 controlled trials under the topic ethyl glucuronide.8,19-21 These 5 studies represent the only high-quality evidence regarding EtG applying to EtG. Information provided by the five studies suggests the following, and only the following:

  1. EtG and EtS measurements increase with alcohol ingestion.
  2. The window of detection is shorter than what is commonly proposed (80 hours).
  3. Individual values are variable both within and between subjects.
  4. Non alcoholic wine can cause positive levels.

Notably, there are no studies that fit Cochrane Criteria, other than non-alcoholic wine, that look at the pharmacokinetics of EtG or EtS in terms of dose-response curves, cut-off levels, specificity drug and food interactions, or modes of ingestion.

SAMHSA notes that there is little research on PEth and that EtG, EtS, and PEth “do not have a strong research base,” and that “it is not known at this time how the test results might be affected by the presence of physical diseases, ethnicity, gender, time, or the use of other drugs. Until considerable more research has occurred, use of these markers should be considered experimental.”

Phosphatidylethanol (PEth), SCRAM, and the  yields no data as a test in the Cochrane library.

SAMHSA notes that there is little research on PEth and that EtG, EtS, and PEth “do not have a strong research base,” and that “it is not known at this time how the test results might be affected by the presence of physical diseases, ethnicity, gender, time, or the use of other drugs. Until considerable more research has occurred, use of these markers should be considered experimental.”

Evidence based medicine (EBM) can be defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.22

Medical progress and scientific advancement is occurring so fast that the volume of medical literature is expanding at a rate of greater than 7% per year.23

Evidence based medicine is not restricted to randomized trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions.22  

Expert opinion is the lowest level of evidence available in the EBM paradigm.24,25

Fortunately, the scientific method is a tool to help people progress toward the truth despite their susceptibilities to confirmation bias and other errors.26

Unfortunately, due to a confluence of factors (including political) this has not been done.  But, unless we want a  future as envisioned by Robert Dupont and explained in the the ASAM White Paper on Drug Testing we need to act now.  This is not a “New Paradigm” but a “New Inquisition.”

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  1. Wurst FM, Kempter C, Seidl S, Alt A. Ethyl glucuronide–a marker of alcohol consumption and a relapse marker with clinical and forensic implications. Alcohol Alcohol. Jan-Feb 1999;34(1):71-77.
  2. Skipper GE, Weinmann W, Thierauf A, et al. Ethyl glucuronide: a biomarker to identify alcohol use by health professionals recovering from substance use disorders. Alcohol Alcohol. Sep-Oct 2004;39(5):445-449.
  3. Wurst FM, Vogel R, Jachau K, et al. Ethyl glucuronide discloses recent covert alcohol use not detected by standard testing in forensic psychiatric inpatients. Alcohol Clin Exp Res. Mar 2003;27(3):471-476.
  4. Costantino A, Digregorio EJ, Korn W, Spayd S, Rieders F. The effect of the use of mouthwash on ethylglucuronide concentrations in urine. J Anal Toxicol. Nov-Dec 2006;30(9):659-662.
  5. Reisfield GM, Goldberger BA, Pesce AJ, et al. Ethyl glucuronide, ethyl sulfate, and ethanol in urine after intensive exposure to high ethanol content mouthwash. J Anal Toxicol. Jun 2011;35(5):264-268.
  6. Rosano TG, Lin J. Ethyl glucuronide excretion in humans following oral administration of and dermal exposure to ethanol. J Anal Toxicol. Oct 2008;32(8):594-600.
  7. Thierauf A, Gnann H, Wohlfarth A, et al. Urine tested positive for ethyl glucuronide and ethyl sulphate after the consumption of “non-alcoholic” beer. Forensic Sci Int. Oct 10 2010;202(1-3):82-85.
  8. Hoiseth G, Yttredal B, Karinen R, Gjerde H, Christophersen A. Levels of ethyl glucuronide and ethyl sulfate in oral fluid, blood, and urine after use of mouthwash and ingestion of nonalcoholic wine. J Anal Toxicol. Mar 2010;34(2):84-88.
  9. Musshoff F, Albermann E, Madea B. Ethyl glucuronide and ethyl sulfate in urine after consumption of various beverages and foods–misleading results? Int J Legal Med. Nov 2010;124(6):623-630.
  10. Administration SAaMHS. The role of biomarkers in the treatment of alcohol use disorders. In: Advisory SAT, ed2006:1-7.
  11. Helliker K. A test for alcohol–and its flaws. The Wall Street Journal2006.
  12. Wurst FM, Skipper GE, Weinmann W. Ethyl glucuronide–the direct ethanol metabolite on the threshold from science to routine use. Addiction. Dec 2003;98 Suppl 2:51-61.
  13. Wurst FM, Alling C, Aradottir S, et al. Emerging biomarkers: new directions and clinical applications. Alcoholism, clinical and experimental research. Mar 2005;29(3):465-473.
  14. Anton RF. Commentary on: ethyl glucuronide and ethyl sulfate assays in clinical trials, interpretation, and limitations: results of a dose ranging alcohol challenge study and 2 clinical trials. Alcoholism, clinical and experimental research. Jul 2014;38(7):1826-1828.
  15. Hernandez Redondo A, Schroeck A, Kneubuehl B, Weinmann W. Determination of ethyl glucuronide and ethyl sulfate from dried blood spots. International journal of legal medicine. Jul 2013;127(4):769-775.
  16. Skipper GE, Thon N, Dupont RL, Baxter L, Wurst FM. Phosphatidylethanol: the potential role in further evaluating low positive urinary ethyl glucuronide and ethyl sulfate results. Alcoholism, clinical and experimental research. Sep 2013;37(9):1582-1586.
  17. Hahn JA, Dobkin LM, Mayanja B, et al. Phosphatidylethanol (PEth) as a biomarker of alcohol consumption in HIV-positive patients in sub-Saharan Africa. Alcoholism, clinical and experimental research. May 2012;36(5):854-862.
  18. Skipper GE, Thon N, DuPont RL, Campbell MD, Weinmann W, Wurst FM. Cellular photo digital breathalyzer for monitoring alcohol use: a pilot study. European addiction research. 2014;20(3):137-142.
  19. Hoiseth G, Bernard JP, Stephanson N, et al. Comparison between the urinary alcohol markers EtG, EtS, and GTOL/5-HIAA in a controlled drinking experiment. Alcohol Alcohol. Mar-Apr 2008;43(2):187-191.
  20. Wojcik MH, Hawthorne JS. Sensitivity of commercial ethyl glucuronide (ETG) testing in screening for alcohol abstinence. Alcohol Alcohol. Jul-Aug 2007;42(4):317-320.
  21. Sarkola T, Dahl H, Eriksson CJ, Helander A. Urinary ethyl glucuronide and 5-hydroxytryptophol levels during repeated ethanol ingestion in healthy human subjects. Alcohol Alcohol. Jul-Aug 2003;38(4):347-351.
  22. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. Jan 13 1996;312(7023):71-72.
  23. Norwitz ER, Greenberg JA. Promoting evidence-based medicine. Rev Obstet Gynecol. Summer 2008;1(3):93-94.
  24. Shaneyfelt TM, Centor RM. Reassessment of clinical practice guidelines: go gently into that good night. JAMA. Feb 25 2009;301(8):868-869.
  25. Straus SE, Green ML, Bell DS, et al. Evaluating the teaching of evidence based medicine: conceptual framework. BMJ. Oct 30 2004;329(7473):1029-1032.

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The ASAM plan to exploit the doctor-patient relationship to drug test everyone they can using non-FDA approved tests they introduced: And you and your doctor won’t have a choice in the matter.

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Before the  2012 Drug and Alcohol Testing Industry Association (DATIA)  annual conference, former Nixon Drug Czar Dr. Robert Dupont delivered a speech entitled “Drug Testing and the Future of American Drug Policy.”   Dupont describes a “New Paradigm” for substance abuse treatment that enforces “zero tolerance for alcohol and drug use”  enforced by monitoring with frequent random drug and alcohol tests in which positive tests are “met with swift, certain, but not draconian, consequences.” The paradigm is based on the current Physician Health Programs blueprint.  Dupont states:

“…physician health programs , have set the standard for effective use of drug testing. These pioneering state programs provide services to health care professionals with substance use disorders. The programs are run by physicians, some of whom in recovery themselves. PHPs feature relatively brief but highly focused treatment followed by active lifelong participation in the 12-step fellowships of Alcoholics Anonymous and Narcotics Anonymous. The key to the success of the PHP system of care management is the enforcement of the standard of zero tolerance for any alcohol or other drug use by intensive long-term random testing for both alcohol and drugs with swift and certain consequences for even a single use of alcohol or any other drugs of abuse. PHPs use drug panels of 20 or more drugs. The PHPs commonly use EtG and EtS tests to detect recent alcohol use. Similar comprehensive programs have been developed for commercial pilots and attorneys. These innovative programs of care management produce unprecedented long-term, outcomes.”

Physician Health Programs (PHPs) use a doctor’s medical license as “leverage” in what they call “contingency management.”  The doctor must comply with any and all demands made under threat of being reported to their medical board for “non-compliance.”  The national organization representing PHPs, the Federation of State Physician Health Programs (FSPHP) has convinced the national organization representing state medical boards, the Federation of State Medical Boards (FSMB) that “second-guessing” PHP authority “undermines a culture of professionalism.”   As with every other ware the FSPHP has pitched the FSMB they accepted this notion in blind faith and without critical analysis. If they did look a little deeper they would find the “PHPs-blueprint” more resembles a paradigm of “racketeering” then it does “rehabilitation” or “recovery” and the terms they use are euphemisms.  Taking a medical license “hostage” and holding it for “ransom”  while putting coins in your pocket by “extortion” doesn’t fit in with a “culture of professionalism” though.  They are very good at impression management–have to give them that.

Declaring the PHP model the “gold standard” of substance abuse treatment they now want to spread the wealth to others, including kids.    But instead of a medical license it will be your student loan, right to participate in school sports, teaching license, hairdressing license, commercial truck driving license, gun license, and even license to drive they will be after.  If you got it and it is in any way tied to state or federal government benefits or rights they will threaten you with removing it.  And as is being seen in doctors there will not be a damned thing you will be able to do about it.

This is all outlined in the 2013 American Society of Addiction Medicine White Paper on Drug Testing.   If you have not read it yet you need to.   If you read one thing this year make it this as it is under the radar and no one is talking about it.

A Modest Proposal

I implore you to do two things:

1.  Read the ASAM White Paper on Drug Testing in its entirety.  It can be found here and here.

2.  If you like what you see do nothing.  If this is the predominant response then it will surely come to fruition as has every other public policy recommendation the ASAM has pushed.  ( See policy entrepreneurship, bent science,  moral crusades).

3. If you don’t like what you see then stand up!  Make your voice known.  Make your voice known in every venue you can.  Write and call your local and state politicians,  comment in the news media, tweet, Instagram, post to FaceBook, send links to your connections on Linkedin. Do everything you can because we do not have long.  The ASAM is slated to become recognized by the American Board of Medical Specialties in 2016 and that will be the beginning of the end.  What is described in the ASAM White Paper will be ushered in and, as we have seen with what has happened to doctors, there will not be a thing you will be able to do about it.

The ASAM is not a medical “specialty” but a “special interest group representing the billion dollar drug and alcohol testing, assessment and treatment industry.   Although they say they exist to help addicts and benefit the public their plans as outlined below suggest they do neither.   Moreover, many of the architects of this future drug-testing dystopia can be found right here on this list.

In order to prevent this we need voices now!  Please take the ASAM White Paper on Drug Testing Challenge.  Read it, form an opinion and state, yell and shout  your opinion everywhere and anywhere you can.


The 2013 American Society of Addiction Medicine White Paper on Drug Testing describes the organizational structure of the “New Paradigm” which includes utilization of the medical profession as a urine collection agency for their drug and alcohol testing. When a doctor-patient relationship exists the testing is rendered “clinical” rather than “forensic.” Thus the consequences of a positive test can be deemed “treatment” rather than punishment. This bypasses the strict chain-of-custody and Medical Review Officer requirements designed to ensure accuracy and minimize false-positives.  Forensic drug testing is tightly regulated because the results a positive test can be grave and far reaching.  Erroneous results are unacceptable.

And then he proposed expansion of this paradigm to other populations including workplace, healthcare, and schools.


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Chain-of-Custody refers to the document or paper trail showing the collection, control, transfer, analysis and disposition of laboratory tests.  It is the written documentation of a specimen from the moment of collection to the final destination to the review and reporting of the final results.   The multi-part chain-of-custody form or “custody and control” form is part and parcel of this process. It contains stickers to sign and seal the specimen so that it cannot be tampered with and the form itself is signed by the appropriate parties as the test specimen travels from place to place. Information is added to the form as it travels from person to person.  It has been given the status of a legal document as it has the ability to invalidate a specimen with incomplete information.  Once the sample is analyzed it is reviewed by a Medical Review Officer (MRO) for final review. In the case of a positive test it is the responsibility of the MRO to ascertain an intact  chain-of-custody, determine whether an alternative explanation exists for the positive test such as a prescribed medication, and then and only then report the test as a “true positive.”

The MRO looks for what are called “fatal flaws” and,  should one be present, invalidates the test.  A fatal flaw requires the test be rejected as it were never drawn.  It invalidates it and it cannot be used. screen-shot-2013-12-19-at-12-20-46-pmAny and all drug testing requires strict  chain-of-custody procedures. It documents not only the whereabouts of the specimen at any given time but the management and storage of the specimen. This is important because time and temperature can influence the results of certain tests.  One such test is alcohol.

Specimen integrity is critical in forensic drug testing, but so too is the integrity of the people involved.


Forensic Versus Clinical Drug Testing

According to the ASAM White Paper on Drug Testing, clinical drug-testing “employs the same sound procedures, safeguard, and systems of information management that are used for all other health-related laboratory tests, tests on which life-and-death medical decisions are commonly made.”  In the box below they describe the multiple safeguards in place and requirements demanded of “forensic” drug testing but do not mention the reason these uncompromising and multiple specifications exist is to protect the donor from a false accusation of drug or alcohol use.  They proceed to define “clinical drug testing” as “part of a patient examination performed for the purposes of diagnosis, treatment, and the promotion of long term recovery” noting that clinical testing “must meet the established standards of medical practice and benefit the therapeutic relationship, rather than meeting the formal legal requirements of forensic testing.”  The authors then state that the “majority of drug testing done today” includes both forensic and clinical elements using individuals on parole and probation as examples.

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From the ASAM White Paper on Drug Testing

The logical fallacy here is striking.  It is comparing apples and oranges.  After detailing the specific quality assurance safeguards designed to prevent the donor of a drug or alcohol test from being falsely accused of illicit use, the authors give a general  definition and purpose of  “clinical” testing  then state that when testing for drugs the systems in place are up to snuff as it is already being used to make  life-and-death medical decisions.  The take-home message is that “forensic” testing is unnecessary hyperbole designed for legal challenges. The clinical lab  systems in place are used for critically  important testing so it can be used for drug-testing.   After all, parolees and probationers don’t require it.

Forensic guidelines were developed in collaboration with occupational and environmental medicine specialists, clinical and forensic toxicologists, pathologists and others and the recommended  requirements agreed upon by this consortium exists solely to  assure validity and accuracy in the testing process.  These requirements exist to protect the donor and If the “clinical” testing context fit the bill then “forensic” testing would not have evolved.

Labs ordered clinically in the course of patient care are interpreted within the context of multiple other pieces of data.  Lab errors occur all the time and are interpreted in that context. Oftentimes a lab will not fit with the clinical picture and, when that happens, a repeat lab is ordered for verification.  Specimens get collected in the wrong tube and specimens get lost but in the clinical setting they simply get reordered and there are no consequences to patient care.   In contrast drug testing is an all-or-none one-shot test and the results have consequences. It is for that reason they must be valid.  Chain-of-custody and MRO review are critical and that is why most drug-testing programs follow the forensic protocol.  And the example of non-forensic drug-testing  parolees and probationers is misleading.   Any Employee Assistance Program that has a union or some other group looking out for their best interests uses strict “forensic” guidelines.   Parolees and probationers have no power  and have no choice.  Besides, the  National Association of Drug Court Professionals uses the Laboratory Developed Tests these same people introduced to test  individuals on probation or parole in the criminal justice system just as they do in the PHPs.

The  ASAM White Paper:

 “Encourages wider and “smarter” use of drug testing within the practice of medicine and, beyond that, broadly within American society. Smarter drug testing means increased use of random testing* rather than the more common scheduled testing,* and it means testing not only urine but also other matrices such as blood, oral fluid (saliva), hair, nails, sweatand breath when those matrices match the intended assessment process. In addition, smarter testing means testing based upon clinical indication for a broad and rotating panel of drugs”

As a physician-patient relationship renders drug testing “clinical” rather than “forensic” the consequences become “treatment” rather than “discipline.”  And that is the real reason behind all of this.    A positive “forensic” test in most employee random drug screening programs today will result in an “assessment” for substance abuse.  Most EAPs allow a choice in where that assessment takes place.  The model this system is based on, Physician Health Programs. does not allow choice as evaluations are mandated to “PHP-approved” assessment centers; a rigged game.

A positive “clinical” test will result in the same thing under the ASAM White Paper proposal.  But the assessment will be at an ASAM facility and if a Substance Use Disorder (SUD) is confirmed it will result in mandated abstinence of all substances (including alcohol) and lifelong spirituality involving 12-step recovery   And by using the healthcare system as a loophole and calling this testing “clinical” rather than “forensic” the ASAM will have successfully introduced widespread testing of a variety of Laboratory Developed Tests (LDTs) of unknown validity while removing  the safeguards provided by forensic testing including chain-of-custody and MRO review.

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